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Wang Z, Feng Z, Zhu D, Wang X, Chen J, Zhu Y, Wang H. Clinical application of combination [ 11C]C-methionine and [ 13N]N-ammonia PET/CT in recurrent functional pituitary adenomas with negative MRI or [ 18F]F-FDG PET/CT. BMC Endocr Disord 2024; 24:19. [PMID: 38311763 PMCID: PMC10840282 DOI: 10.1186/s12902-024-01543-2] [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] [Received: 06/29/2023] [Accepted: 01/19/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND We assessed the value of positron emission tomography/computed tomography (PET/CT) with [13N]N-ammonia ([13N]N-NH3) and [11C]C-methionine ([11C]C-MET) for the evaluation and management of recurrent secreting pituitary adenoma, which could not be detected by magnetic resonance imaging (MRI) or fluorine-18 fluorodeoxyglucose ([18F]F-FDG) PET. METHODS Nine consecutive patients with biochemical and clinical evidence of active recurrent tumor not detected by MRI and [18F]F-FDG PET were enrolled in this study. All of the patients underwent [13N]N-NH3 and [11C]C-MET PET/CT, after which the pattern of tracer uptake was studied, the tumor position was located, and a clinical decision was made. RESULTS In general, [11C]C-MET had a higher uptake in pituitary adenomas (PAs) than that in pituitary tissues, while [13N]N-NH3 had a higher uptake in pituitary tissue than in pituitary adenomas. Increased [11C]C-MET uptake was observed in all nine PAs and three pituitary tissues, while all pituitary tissues and only one pituitary adenoma showed increased [13N]N-NH3 uptake. Four patients had concordant imaging and surgical findings indicative of biochemical remission without hypopituitarism after treatment. Radiotherapy was adopted in two patients, medication in another two, and follow-up observation in one case. CONCLUSION Combined [11C]C-MET and [13N]N-NH3 PET/CT is effective in the differentiation of PAs from pituitary tissue in recurrent functional PAs with negative MRI or [18F]F-FDG PET. These results provide a valuable reference for further disease management.
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Affiliation(s)
- Zongming Wang
- Department of Neurosurgery, Pituitary Tumor Center, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Zize Feng
- Department of Neurosurgery, Jiangmen Central Hospital, Guangdong, China
| | - Dimin Zhu
- Department of Neurosurgery, Pituitary Tumor Center, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xin Wang
- Department of Histology and Embryology, School of Basic Medical Sciences, Guangdong Pharmaceutical University, Guangzhou, China
| | - Jinping Chen
- Department of Neurosurgery, Pituitary Tumor Center, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yonghong Zhu
- Department of Histology and Embryology, Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China.
| | - Haijun Wang
- Department of Neurosurgery, Pituitary Tumor Center, the First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
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Cai Y, Liu S, Zhao X, Ren L, Liu X, Gang X, Wang G. Pathogenesis, clinical features, and treatment of plurihormonal pituitary adenoma. Front Neurosci 2024; 17:1323883. [PMID: 38260014 PMCID: PMC10800528 DOI: 10.3389/fnins.2023.1323883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Plurihormonal pituitary adenoma (PPA) is a type of pituitary tumor capable of producing two or more hormones and usually presents as an aggressive, large adenoma. As yet, its pathogenesis remains unclear. This is the first study to systematically summarize the underlying pathogenesis of PPA. The pathogenesis is related to plurihormonal primordial stem cells, co-transcription factors, hormone co-expression, differential gene expression, and cell transdifferentiation. We conducted a literature review of PPA and analyzed its clinical characteristics. We found that the average age of patients with PPA was approximately 40 years, and most showed only one clinical symptom. The most common manifestation was acromegaly. Currently, PPA is treated with surgical resection. However, recent studies suggest that immunotherapy may be a potentially effective treatment.
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Affiliation(s)
| | | | | | | | | | - Xiaokun Gang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Guixia Wang
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
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3
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Maragkos GA, Mantziaris G, Pikis S, Chytka T, Liscak R, Peker S, Samanci Y, Bindal SK, Niranjan A, Lunsford LD, Kaur R, Madan R, Tripathi M, Pangal DJ, Strickland BA, Zada G, Langlois AM, Mathieu D, Warnick RE, Patel S, Minier Z, Speckter H, Kondziolka D, Lee CC, Vance ML, Sheehan JP. Silent Corticotroph Staining Pituitary Neuroendocrine Tumors: Prognostic Significance in Radiosurgery. Neurosurgery 2023; 93:1407-1414. [PMID: 37966247 DOI: 10.1227/neu.0000000000002607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/19/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is conflicting evidence on the significance of adrenocorticotrophic hormone (ACTH) staining in the prognosis of nonfunctioning pituitary neuroendocrine tumors (NFpitNETs). The objective of this study was to define the effect of ACTH immunostaining on clinical and radiographic outcomes of stereotactic radiosurgery (SRS) for NFpitNETs. METHODS This retrospective, multicenter study included patients managed with SRS for NFpitNET residuals. The patients were divided into 2 cohorts: (1) silent corticotroph (SC) for NFpitNETs with positive ACTH immunostaining and (2) non-SC NFpitNETs. Rates of local tumor control and the incidence of post-treatment pituitary and neurological dysfunction were documented. Factors associated with radiological and clinical outcomes were also analyzed. RESULTS The cohort included 535 patients from 14 centers with 84 (15.7%) patients harboring silent corticotroph NFpitNETs (SCs). At last follow-up, local tumor progression occurred in 11.9% of patients in the SC compared with 8.1% of patients in the non-SC cohort (P = .27). No statistically significant difference was noted in new-onset hypopituitarism rates (10.7% vs 15.4%, P = .25) or visual deficits (3.6% vs 1.1%, P = .088) between the 2 cohorts at last follow-up. When controlling for residual tumor volume, maximum dose, and patient age and sex, positive ACTH immunostaining did not have a significant correlation with local tumor progression (hazard ratio = 1.69, 95% CI = 0.8-3.61, P = .17). CONCLUSION In contemporary radiosurgical practice with a single fraction dose of 8-25 Gy (median 15 Gy), ACTH immunostaining in NFpitNETs did not appear to confer a significantly reduced rate of local tumor control after SRS.
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Affiliation(s)
- Georgios A Maragkos
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Tomas Chytka
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Roman Liscak
- Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague , Czech Republic
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul , Turkey
| | - Shray K Bindal
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
| | - Rupinder Kaur
- Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh , India
| | - Renu Madan
- Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh , India
| | - Manjul Tripathi
- Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh , India
| | - Dhiraj J Pangal
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles , California , USA
| | - Ben A Strickland
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles , California , USA
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles , California , USA
| | - Anne-Marie Langlois
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherché du CHUS, Sherbrooke , Québec , Canada
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherché du CHUS, Sherbrooke , Québec , Canada
| | | | - Samir Patel
- Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton , Alberta , Canada
| | - Zayda Minier
- Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo , Dominican Republic
| | - Herwin Speckter
- Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo , Dominican Republic
| | | | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei , Taiwan
| | - Mary Lee Vance
- Department of Endocrinology and Metabolism, University of Virginia Health System, Charlottesville , Virginia , USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville , Virginia , USA
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Clemmons DR, Bidlingmaier M. Interpreting growth hormone and IGF-I results using modern assays and reference ranges for the monitoring of treatment effectiveness in acromegaly. Front Endocrinol (Lausanne) 2023; 14:1266339. [PMID: 38027199 PMCID: PMC10656675 DOI: 10.3389/fendo.2023.1266339] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Standard treatment for acromegaly focuses on the achievement of target absolute levels of growth hormone (GH) and insulin-like growth factor (IGF-I). The appropriateness of these targets when measured using modern assay methods is not well defined. This paper reviews biochemical status assessed using methods available at the time and associated clinical outcomes. GH measurements were shown to provide an indication of changes in tumor size, and failure of GH suppression after glucose stimulation is associated with tumor recurrence. IGF-I levels were more closely associated with changes in symptoms and signs. Reduced GH and IGF-I concentrations were shown to be associated with increased longevity, although the degree of increase has only been analyzed for GH. Lowering of GH and IGF-I has consistently been associated with improved outcomes; however, absolute levels reported in previous studies were based on results from methods and reference ranges that are now obsolete. Applying previously described absolute thresholds as targets (e.g. "normal" IGF-I level) when using current methods is best applied to those with active acromegaly symptoms who could benefit from further lowering of biochemical markers. In asymptomatic individuals with mild IGF-I or GH elevations, targeting biochemical "normalization" would result in the need for combination pharmacotherapy in many patients without proven benefit. Measurement of both GH and IGF-I remains an essential component of diagnosis and monitoring the effectiveness of treatment in acromegaly; however, treatment goals based only on previously identified absolute thresholds are not appropriate without taking into account the assay and reference ranges being employed. Treatment goals should be individualized considering biochemical improvement from an untreated baseline, symptoms of disease, risks, burdens and costs of complex treatment regimens, comorbidities, and quality of life.
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Affiliation(s)
- David R. Clemmons
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Martin Bidlingmaier
- Neuroendocrine Unit, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
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Khan SA, Shafiq W, Azmat U, Siddiqi AI, Alvi AM, Ashfaq S, Irfan H, Bakar MA, Asghar K. Radiation therapy outcomes of patients with pituitary macroadenoma. Biomed Rep 2022; 18:12. [PMID: 36568037 PMCID: PMC9764322 DOI: 10.3892/br.2022.1594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
Pituitary adenomas are one of the most common benign intracranial tumors, which are normally treated with surgery along with radiation therapy and medication such as dopamine agonist in prolactinoma. The aim of the present study was to evaluate the outcome of patients with pituitary macroadenoma who underwent radiation therapy. For the present retrospective study, a total of 75 patients with pituitary macroadenoma who received radiation therapy were included. Data was acquired from the electronic medical record system of the hospital. Mean ± standard deviation of the quantitative variables, such as age and sizes of the tumors, were reported. In addition, frequencies and percentages were presented for all categorical variables. To compare the frequency distribution in radiation therapy characteristics between functional and non-functional tumors, the χ2 test or Fisher's exact test was applied, where appropriate. Kaplan-Meier survival curve was drawn to assess the progression free survival proportion. P≤0.05 was considered to indicate a statistically significant difference. In the present study, all patients (n=75) with pituitary macroadenoma were treated with radiation therapy (RT). The mean age was 38.55±1.36 years and the majority of the patients were male (43; 57.3%). The mean tumor size was 3.84±1.43 cm. In total, 66.7% were non-functional tumors whereas 33.3% were functional tumors that produce hormones in excess [growth hormone (72%), prolactin (16%), both growth hormone and prolactin (8%) and adrenocorticotropic hormone (4%)]. The overall outcome was revealed to be 92% achieving local tumor control and 28% achieving biochemical control. Hypopituitarism (38.7%) and visual acuity deterioration (9.3%) were the most common complications observed following RT. The overall progression-free survival at 2 years was 92%. In conclusion, the data of the present study suggested that local tumor control in non-functional and functional pituitary macroadenoma can be well managed with RT. However, biochemical control to normalize hormones overproduction in functional pituitary macroadenoma was not as effective as local tumor control.
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Affiliation(s)
- Sardar Ali Khan
- Department of Endocrinology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab 54000, Pakistan
| | - Waqas Shafiq
- Department of Endocrinology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab 54000, Pakistan,Correspondence to: Dr Waqas Shafiq, Department of Endocrinology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, 7-A Khayaban-e-Firdousi Block R-3 Johar Town, Lahore, Punjab 54000, Pakistan
| | - Umal Azmat
- Department of Endocrinology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab 54000, Pakistan
| | - Ahmed Imran Siddiqi
- Department of Endocrinology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab 54000, Pakistan
| | - Asim Munir Alvi
- Department of Endocrinology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab 54000, Pakistan
| | - Sara Ashfaq
- Department of Endocrinology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab 54000, Pakistan
| | - Hira Irfan
- Department of Endocrinology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab 54000, Pakistan
| | - Muhammad Abu Bakar
- Department of Cancer Registry and Clinical Data Management, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab 54000, Pakistan
| | - Kashif Asghar
- Department of Basic Sciences Research, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Punjab 54000, Pakistan
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Charleux T, Vendrely V, Huchet A, Trouette R, Ferrière A, Tabarin A, Jecko V, Loiseau H, Dupin C. Management after initial surgery of nonfunctioning pituitary adenoma: surveillance, radiotherapy or surgery? Radiat Oncol 2022; 17:165. [PMID: 36229880 PMCID: PMC9559766 DOI: 10.1186/s13014-022-02133-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction The first line of treatment for nonfunctioning pituitary adenoma (NFPA) is surgery. Adjuvant radiotherapy or surveillance and new treatment (second surgical operation or salvage radiotherapy) in case of recurrence are options discussed at the multidisciplinary tumor board. The purpose of this study was to evaluate the therapeutic outcome for each option. Methods The records of 256 patients followed with NFPA between 2007 and 2018 were retrospectively reviewed. Mean age at initial surgery was 55 years [18–86]. Post-operative MRI found a residual tumor in 87% of patients. Mean follow-up was 12.1 years [0.8–42.7]. Results After initial surgery, 40 patients had adjuvant radiotherapy. At 5, 10 and 15 years progression-free survival (PFS) was significantly different after surgery alone (77%, 58% and 40%) compared to surgery and adjuvant radiotherapy (84%, 78% and 78%) (HR = 0.24 [0–0.53] p < 0.0005). Overall, after first, second or third surgical operation, 69 patients had adjuvant radiotherapy and 41 salvage radiotherapy. Five-year PFS was similar for adjuvant (90%) and salvage radiotherapy (97%) (p = 0.62). After a second surgical operation, 62% and 71% of patients were irradiated after 2 and 5 years respectively. The risk of corticotropic and thyrotropic deficiency rates were 38% and 59% after second or third surgical operation and 40% and 73% after radiotherapy. Brain tumors occurred in 4 patients: 1 meningioma present at initial surgery, and after radiotherapy, 1 neurinoma which appeared at 5 years, 1 glioblastoma at 13 years and 1 meningioma at 20 years. Conclusion Among patients treated by surgery for NFPA, a “wait-and-see” attitude should be an option since adjuvant radiotherapy is not superior to salvage radiotherapy. However, in case of recurrence or progression, the authors recommended delivery of salvage radiotherapy to avoid a second surgical operation. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-022-02133-z.
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Affiliation(s)
- Thomas Charleux
- Radiotherapy Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Véronique Vendrely
- Radiotherapy Department, CHU Bordeaux, 33000, Bordeaux, France.,BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, 33000, Bordeaux, France
| | - Aymeri Huchet
- Radiotherapy Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Renaud Trouette
- Radiotherapy Department, CHU Bordeaux, 33000, Bordeaux, France
| | | | - Antoine Tabarin
- Endocrinology Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Vincent Jecko
- Neurosurgery Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Hugues Loiseau
- Neurosurgery Department, CHU Bordeaux, 33000, Bordeaux, France
| | - Charles Dupin
- Radiotherapy Department, CHU Bordeaux, 33000, Bordeaux, France. .,BRIC (BoRdeaux Institute of onCology), UMR1312, INSERM, University of Bordeaux, 33000, Bordeaux, France.
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7
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Ironside N, Snyder H, Xu Z, Schlesinger D, Chen CJ, Vance ML, Hong GK, Jane JA, Sheehan JP. Effect of distance from target on hypopituitarism after stereotactic radiosurgery for pituitary adenomas. J Neurooncol 2022; 158:41-50. [DOI: 10.1007/s11060-022-04007-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
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9
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Bray DP, Mannam S, Rindler RS, Quillin JW, Oyesiku NM. Surgery for acromegaly: Indications and goals. Front Endocrinol (Lausanne) 2022; 13:924589. [PMID: 35992136 PMCID: PMC9386525 DOI: 10.3389/fendo.2022.924589] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/29/2022] [Indexed: 12/02/2022] Open
Abstract
Acromegaly is a disease that occurs secondary to high levels of GH, most often from a hormone-secreting pituitary adenoma, with multisystem adverse effects. Diagnosis includes serum GH and IGF-1 levels, and obtaining an MRI pituitary protocol to assess for a functional pituitary adenoma. Attempted gross total resection of the GH-secreting adenoma is the gold standard in treatment for patients with acromegaly for a goal of biochemical remission. Medical and radiation therapies are available when patients do not achieve biochemical cure after surgical therapy.
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Affiliation(s)
- David P Bray
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Sai Mannam
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Rima S Rindler
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, United States
| | - Joseph W Quillin
- Department of Neurosurgery, Medical City Hospital, Dallas, TX, United States
| | - Nelson M Oyesiku
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, NC, United States
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10
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Du Four S, Van Der Veken J, Duerinck J, Vermeulen E, Andreescu CE, Bruneau M, Neyns B, Velthoven V, Velkeniers B. Pituitary carcinoma - case series and review of the literature. Front Endocrinol (Lausanne) 2022; 13:968692. [PMID: 36157469 PMCID: PMC9493437 DOI: 10.3389/fendo.2022.968692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/15/2022] [Indexed: 12/03/2022] Open
Abstract
Although pituitary adenomas (PAs) account for 15% of intracranial tumors, pituitary carcinomas (PCs) are a rare entity. Most commonly, PCs evolve from aggressive PAs invading the surrounding structures and eventually leading to metastatic lesions. Due to the low incidence, the diagnosis and treatment remains challenging. We report a case series of five patients with pituitary carcinoma (PC) treated in our center. At first diagnosis 3 patients had an ACTH-producing adenoma, 1 a prolactinoma and 1 a double secreting adenoma (GH and prolactin). The mean time interval from initial diagnosis to diagnosis of PC was 10.7 years (range 5-20 years). All patients underwent multiple surgical resections and radiotherapy. Four patients were treated with temozolomide for metastatic disease. One patient with concomitant radiochemotherapy for local recurrence. Temozolomide led to a stable disease in 2 patients. One patient had a progressive disease after 9 cycles of temozolomide. In absence of standard treatment, immunotherapy was initiated, resulting in a stable disease. We report five cases of PCs. Three patients obtained a stable disease after tailored multidisciplinary treatment. Additionally, one patient was treated with immunotherapy, opening a new treatment option in PCs. Overall, PCs are rare intracranial neoplasms occurring several years after the initial diagnosis of aggressive PAs. Currently, the absence of predictive factors for an aggressive clinical course, provokes a challenging management.
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Affiliation(s)
- Stephanie Du Four
- Department of Neurosurgery, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
- Department of Neurosurgery, AZ Delta, Roeselare, Belgium
- *Correspondence: Stephanie Du Four,
| | - Jorn Van Der Veken
- Department of Neurosurgery, Flinders Medical Centre, Adelaide, SA, Australia
| | | | - Elle Vermeulen
- Department of Neurosurgery, AZ Delta, Roeselare, Belgium
| | - Corina E. Andreescu
- Department of Endocrinology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | - Bart Neyns
- Department of Medical Oncology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Van Velthoven
- Department of Neurosurgery, AZ Delta, Roeselare, Belgium
| | - Brigitte Velkeniers
- Department of Internal Medicine, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Dissaux G, Josset S, Thillays F, Lucia F, Bourbonne V, Pradier O, Pasquier D, Biau J. Radiotherapy of benign intracranial tumours. Cancer Radiother 2021; 26:137-146. [PMID: 34953692 DOI: 10.1016/j.canrad.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
We present the updated recommendations of the French Society for Radiation Oncology on benign intracranial tumours. Most of them are meningiomas, vestibular schwannomas, pituitary adenomas, craniopharyngiomas, and glomus tumours. Some grow very slowly, and can be observed without specific treatment, especially if they are asymptomatic. Symptomatic or growing tumours are treated by surgery, which is the reference treatment. When surgery is not possible, due to the location of the lesion, or general conditions, radiotherapy can be applied, as it is if there is a postoperative growing residual tumour, or a local relapse. Indications have to be discussed at a multidisciplinary panel, with precise evaluation of the benefit and risks of the treatments. The techniques to be used are the most modern ones, as multimodal imaging and image-guided radiation therapy. Stereotactic treatments, using fractionated or single doses depending on the size or the location of the tumours, are commonly realized, to avoid as much a possible the occurrence of late side effects.
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Affiliation(s)
- G Dissaux
- Département de radiothérapie, CHRU Morvan, Latim, Inserm, UMR 1101, université de Brest, Isbam, UBO, UBL, 2, avenue Foch, 29200 Brest, France.
| | - S Josset
- Service de physique médicale, Institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - F Thillays
- Département de radiothérapie, Institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - F Lucia
- Département de radiothérapie, CHRU Morvan, Latim, Inserm, UMR 1101, université de Brest, Isbam, UBO, UBL, 2, avenue Foch, 29200 Brest, France
| | - V Bourbonne
- Département de radiothérapie, CHRU Morvan, Latim, Inserm, UMR 1101, université de Brest, Isbam, UBO, UBL, 2, avenue Foch, 29200 Brest, France
| | - O Pradier
- Département de radiothérapie, CHRU Morvan, Latim, Inserm, UMR 1101, université de Brest, Isbam, UBO, UBL, 2, avenue Foch, 29200 Brest, France
| | - D Pasquier
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France; Centre de recherche en informatique, signal et automatique de Lille (Cristal) UMR 9189, université de Lille, 59000 Lille, France
| | - J Biau
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, 63011 Clermont-Ferrand, France; Inserm, U1240 Imost, université Clermont-Auvergne, 63011 Clermont-Ferrand, France
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12
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MicroRNAs as Potential Biomarkers in Pituitary Adenomas. Noncoding RNA 2021; 7:ncrna7030055. [PMID: 34564317 PMCID: PMC8482103 DOI: 10.3390/ncrna7030055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 12/16/2022] Open
Abstract
Pituitary adenomas (PAs) are one of the most common lesions of intracranial neoplasms, occurring in approximately 15% of the general population. They are typically benign, although some adenomas show aggressive behavior, exhibiting rapid growth, drug resistance, and invasion of surrounding tissues. Despite ongoing improvements in diagnostic and therapeutic strategies, late first diagnosis is common, and patients with PAs are prone to relapse. Therefore, earlier diagnosis and prevention of recurrence are of importance to improve patient care. MicroRNAs (miRNAs) are short non-coding single stranded RNAs that regulate gene expression at the post-transcriptional level. An increasing number of studies indicate that a deregulation of their expression patterns is related with pituitary tumorigenesis, suggesting that these small molecules could play a critical role in contributing to tumorigenesis and the onset of these tumors by acting either as oncosuppressors or as oncogenes, depending on the biological context. This paper provides an overview of miRNAs involved in PA tumorigenesis, which might serve as novel potential diagnostic and prognostic non-invasive biomarkers, and for the future development of miRNA-based therapeutic strategies for PAs.
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Graffeo CS, Perry A, Link MJ, Brown PD, Young WF, Pollock BE. Biological Effective Dose as a Predictor of Hypopituitarism After Single-Fraction Pituitary Adenoma Radiosurgery: Dosimetric Analysis and Cohort Study of Patients Treated Using Contemporary Techniques. Neurosurgery 2021; 88:E330-E335. [PMID: 33469668 DOI: 10.1093/neuros/nyaa555] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 11/04/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Hypopituitarism is the most frequent complication after pituitary adenoma stereotactic radiosurgery (SRS) and is correlated with increasing radiation to the pituitary gland. Biological effective dose (BED) is a dosimetric parameter that incorporates a time component to adjust for mechanisms of deoxyribonucleic acid repair activated during treatment. OBJECTIVE To assess mean gland BED as a predictor of post-SRS hypopituitarism, as compared to mean gland dose, in a contemporary cohort study of patients undergoing single-fraction SRS for pituitary adenoma. METHODS Cohort study of 97 patients undergoing single-fraction SRS from 2007 to 2014. Eligible patients had no prior pituitary irradiation, normal pre-SRS endocrine function, and >24 mo of endocrine follow-up. Cox proportional hazards analysis was used to assess mean gland dose and BED as predictors of new post-SRS hypopituitarism. RESULTS Median post-SRS follow-up was 48 mo (interquartile range [IQR], 34-68). A total of 27 patients (28%) developed new hypopituitarism at a median 22 mo (IQR, 12-36). Actuarial rates of new endocrinopathy were 17% at 2 yr (95% CI 10%-25%) and 31% at 5 yr (95% CI 20%-42%). On univariate analysis, sex (P = .02), gland volume (P = .03), mean gland dose (P < .0001), and BED significantly predicted new hypopituitarism (P < .0001). After adjusting for sex and gland volume, BED > 45 Gy2.47 and mean gland dose > 10 Gy were significantly associated increased risk of hypopituitarism (hazard ratio [HR] = 14.32, 95% CI = 4.26-89.0, P < .0001; HR = 11.91, 95% CI = 3.54-74.0, P < .0001). CONCLUSION BED predicted hypopituitarism more reliably than mean gland dose after pituitary adenoma SRS, but additional studies are needed to confirm these results.
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Affiliation(s)
| | - Avital Perry
- Departments of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- Departments of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - William F Young
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bruce E Pollock
- Departments of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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14
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Liu X, Dai C, Feng M, Li M, Chen G, Wang R. Diagnosis and treatment of refractory pituitary adenomas: a narrative review. Gland Surg 2021; 10:1499-1507. [PMID: 33968701 DOI: 10.21037/gs-20-873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although aggressive pituitary adenomas (PAs) have been proposed and widely discussed for more than a decade, there is no general agreement regarding their definition, diagnosis or management. As one of the largest pituitary centers in China, we have diagnosed and treated more than fifty cases of aggressive PA and 3 pituitary carcinomas in the past 5 years and proposed a new term, i.e., refractory PAs, to define these adenomas. The definitions of aggressive and refractory PAs overlap with each other, though there are some differences between them. We interpret the definition for refractory PA in this review, emphasizing that more attention and early identification of these adenomas are needed. Although temozolomide (TMZ) has been used to treat pituitary carcinomas and refractory PA since 2006, which has significantly improved the prognosis of these patients, treatment of refractory PA is a tremendous challenge for endocrinologists and neurosurgeons. Overall, refractory PA is defined as PA with a Ki-67 labeling index ≥3%, a faster growth rate than that of normal PA, infiltration of surrounding tissues, recurrence or regrowth in the early postoperative period, and continued growth and/or secretion of excessive hormones despite attempts to control it. These criteria for refractory PA are stricter than for aggressive PA. The diagnosis and treatment of refractory PA requires the collaboration of a multidisciplinary team to achieve the best results.
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Affiliation(s)
- Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Congxin Dai
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Tongren Hospital Capital Medical University, Beijing, China
| | - Ming Feng
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingchu Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Ge Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Renzhi Wang
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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15
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Long-term disease control and treatment outcomes of stereotactic radiosurgery in cavernous sinus meningiomas. J Neurooncol 2021; 152:439-449. [PMID: 33772678 DOI: 10.1007/s11060-021-03732-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Most of the current knowledge on the clinical effects of stereotactic radiosurgery (SRS) on the treatment of cavernous sinus meningiomas (CSM) is based on series with limited follow-up. However, determining the role of radiation in a tumor with slow disease progression such as CSM necessitates long term follow up. OBJECTIVE To review and pool metadata in the literature to determine the long-term outcomes of SRS with respect to clinical and radiographic tumor control of CSM. METHODS A systematic search was conducted following MOOSE guidelines. Results were screened against predefined criteria, which excluded studies with a median follow-up less than 5 years. The incidences of each outcome were calculated using random-effects metanalysis of proportions. RESULTS Seven studies met the inclusion criteria, comprising 645 patients. The median follow-up was 74 months (range 62-87). Progression-free-survival at 5, 10, and 15 years was 93.4% (95% CI 89.1-96.7%), 84.9% (95% CI 77-91.4%), and 81.3% (95% CI 74-87.7%), respectively. Clinical response to SRS at last follow-up defined as improvement of cranial nerve deficits was found in in 36.4% (95% CI 26.3-47.1%) of patients, while worsening or onset of new cranial nerve deficits was found in 11.5% (95% CI 7.9-15.7%). Radiological regression was found in 57.8% (95% CI 43-71.8%), while tumor progression was found in 8.5% (95% CI 5.2-12.6%). CONCLUSION SRS achieves excellent disease control and radiographic response in CSM. Although the risk of long-term cranial neuropathies is minimal, it is relatively higher to what has been previously reported in early series with limited follow-up.
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16
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Ehret F, Kufeld M, Fürweger C, Haidenberger A, Windisch P, Fichte S, Lehrke R, Senger C, Kaul D, Rueß D, Ruge M, Schichor C, Tonn JC, Stalla G, Muacevic A. Robotic Radiosurgery for Persistent Postoperative Acromegaly in Patients with Cavernous Sinus-Invading Pituitary Adenomas-A Multicenter Experience. Cancers (Basel) 2021; 13:cancers13030537. [PMID: 33572555 PMCID: PMC7866786 DOI: 10.3390/cancers13030537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/12/2021] [Accepted: 01/28/2021] [Indexed: 11/25/2022] Open
Abstract
Simple Summary Growth hormone-secreting tumors of the pituitary gland which infiltrate surrounding tissue structures may not be fully resectable. This causes many patients to suffer from acromegaly after an unsuccessful surgery. To limit the considerable morbidity and mortality of such patients, effective and safe treatment options are needed. Fractionated radiotherapy and growth hormone-lowering medication are possible treatment options. Robotic radiosurgery (RRS) may be a suitable treatment modality as well. However, only sparse and heterogeneous data are available. This first retrospective multicenter study investigated the efficacy and safety of RRS for this patient group. Outcomes provide evidence that RRS may achieve biochemical disease control or remission in most of the patients. The hormone levels are decreasing after treatment, whereas favorable risk and safety profiles of RRS were shown. No new tumor growth was observed throughout the available follow-up. These findings may guide future care for this challenging patient population. Abstract Background: The rates of incomplete surgical resection for pituitary macroadenomas with cavernous sinus invasion are high. In growth hormone-producing adenomas, there is a considerable risk for persistent acromegaly. Thus, effective treatment options are needed to limit patient morbidity and mortality. This multicenter study assesses the efficacy and safety of robotic radiosurgery (RRS) for patients with cavernous sinus-invading adenomas with persistent acromegaly. Methods: Patients who underwent RRS with CyberKnife for postoperative acromegaly were eligible. Results: Fifty patients were included. At a median follow-up of 57 months, the local control was 100%. The pretreatment insulin-like growth factor 1 (IGF-1) levels and indexes were 381 ng/mL and 1.49, respectively. The median dose and prescription isodose were 18 Gy and 70%, respectively. Six months after RRS, and at the last follow-up, the IGF-1 levels and indexes were 277 ng/mL and 1.14, as well as 196 ng/mL and 0.83, respectively (p = 0.0001 and p = 0.0002). The IGF-1 index was a predictor for biochemical remission (p = 0.04). Nine patients achieved biochemical remission and 24 patients showed biochemical disease control. Three patients developed a new hypopituitarism. Conclusions: RRS is an effective treatment for this challenging patient population. IGF-1 levels are decreasing after treatment and most patients experience biochemical disease control or remission.
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Affiliation(s)
- Felix Ehret
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (C.S.); (D.K.)
- European Cyberknife Center, 81377 Munich, Germany; (M.K.); (C.F.); (A.H.); (P.W.); (A.M.)
- Correspondence:
| | - Markus Kufeld
- European Cyberknife Center, 81377 Munich, Germany; (M.K.); (C.F.); (A.H.); (P.W.); (A.M.)
| | - Christoph Fürweger
- European Cyberknife Center, 81377 Munich, Germany; (M.K.); (C.F.); (A.H.); (P.W.); (A.M.)
| | - Alfred Haidenberger
- European Cyberknife Center, 81377 Munich, Germany; (M.K.); (C.F.); (A.H.); (P.W.); (A.M.)
| | - Paul Windisch
- European Cyberknife Center, 81377 Munich, Germany; (M.K.); (C.F.); (A.H.); (P.W.); (A.M.)
- Department of Radiation Oncology, Kantonsspital Winterthur, 8400 Winterthur, Switzerland
| | - Susanne Fichte
- CyberKnife Center Mitteldeutschland, 99089 Erfurt, Germany;
| | | | - Carolin Senger
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (C.S.); (D.K.)
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité CyberKnife Center, 13353 Berlin, Germany
| | - David Kaul
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Radiation Oncology, 13353 Berlin, Germany; (C.S.); (D.K.)
- German Cancer Consortium (DKTK), Partner Site Berlin, German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Daniel Rueß
- Department of Stereotaxy and Functional Neurosurgery, Center for Neurosurgery, University Hospital Cologne, 50937 Cologne, Germany; (D.R.); (M.R.)
| | - Maximilian Ruge
- Department of Stereotaxy and Functional Neurosurgery, Center for Neurosurgery, University Hospital Cologne, 50937 Cologne, Germany; (D.R.); (M.R.)
| | - Christian Schichor
- Department of Neurosurgery, Ludwig-Maximilians-University Munich, 81377 Munich, Germany; (C.S.); (J.-C.T.)
| | - Jörg-Christian Tonn
- Department of Neurosurgery, Ludwig-Maximilians-University Munich, 81377 Munich, Germany; (C.S.); (J.-C.T.)
| | - Günter Stalla
- Medicover Neuroendocrinology, 81667 Munich, Germany;
- Department of Medicine IV, Ludwig-Maximilians-University Munich, 81377 Munich, Germany
| | - Alexander Muacevic
- European Cyberknife Center, 81377 Munich, Germany; (M.K.); (C.F.); (A.H.); (P.W.); (A.M.)
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Cooper O, Bonert V, Liu NA, Mamelak AN. Treatment of Aggressive Pituitary Adenomas: A Case-Based Narrative Review. Front Endocrinol (Lausanne) 2021; 12:725014. [PMID: 34867776 PMCID: PMC8634600 DOI: 10.3389/fendo.2021.725014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/28/2021] [Indexed: 12/29/2022] Open
Abstract
Management of aggressive pituitary adenomas is challenging due to a paucity of rigorous evidence supporting available treatment approaches. Recent guidelines emphasize the need to maximize standard therapies as well as the use of temozolomide and radiation therapy to treat disease recurrence. However, often these adenomas continue to progress over time, necessitating the use of additional targeted therapies which also impact quality of life and long-term outcomes. In this review, we present 9 cases of aggressive pituitary adenomas to illustrate the importance of a multidisciplinary, individualized approach. The timing and rationale for surgery, radiation therapy, temozolomide, somatostatin receptor ligands, and EGFR, VEGF, and mTOR inhibitors in each case are discussed within the context of evidence-based guidelines and clarify strategies for implementing an individualized approach in the management of these difficult-to-treat-adenomas.
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Affiliation(s)
- Odelia Cooper
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- *Correspondence: Odelia Cooper,
| | - Vivien Bonert
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Ning-Ai Liu
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Adam N. Mamelak
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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18
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Graffeo CS, Link MJ, Stafford SL, Parney IF, Foote RL, Pollock BE. Risk of internal carotid artery stenosis or occlusion after single-fraction radiosurgery for benign parasellar tumors. J Neurosurg 2020; 133:1388-1395. [PMID: 31653808 DOI: 10.3171/2019.8.jns191285] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is an accepted treatment option for patients with benign parasellar tumors. Here, the authors' objective was to determine the risk of developing new or progressive internal carotid artery (ICA) stenosis or occlusion after single-fraction SRS for cavernous sinus meningioma (CSM) or growth hormone-secreting pituitary adenoma (GHPA). METHODS The authors queried their prospectively maintained registry for patients treated with single-fraction SRS for CSM or GHPA in the period from 1990 to 2015. Study criteria included no prior irradiation and ≥ 12 months of post-SRS radiological follow-up. Pre-SRS grading of ICA involvement was applied according to the 1993 classification schemes of Hirsch for CSM or Knosp for GHPA. RESULTS The authors conducted a retrospective review of 283 patients, 155 with CSMs and 128 with GHPAs. Ninety-three (60%) CSMs were Hirsch category 2 and 3 tumors; 97 (76%) GHPAs were Knosp grade 2-4 tumors. Median follow-up after SRS was 6.6 years (IQR 1-24.9 years). No GHPA or category 1 CSM developed ICA stenosis or occlusion. Three (5.2%) patients with category 2 CSMs had asymptomatic ICA stenosis (n = 2) or occlusion (n = 1); 1 (1.1%) category 2 CSM patient had transient ischemic symptoms. Five (14.3%) category 3 CSMs progressed to ICA occlusion (4 asymptomatic, 1 symptomatic). The median time to stenosis/occlusion was 4.8 years (IQR 1.8-7.6). Five- and 10-year risks of ICA stenosis/occlusion in category 2 and 3 CSM patients were 7.5% and 12.4%, respectively. Five- and 10-year risks of ischemic stroke from ICA stenosis/occlusion in category 2 and 3 CSM patients were both 1.2%. Multivariate analysis showed patient age (HR 0.92, 95% CI 0.86-0.98, p = 0.01), meningioma pathology (HR and 95% CI not defined, p = 0.03), and pre-SRS carotid category (HR 4.51, 95% CI 1.77-14.61, p = 0.004) to be associated with ICA stenosis/occlusion. Internal carotid artery stenosis/occlusion was not related to post-SRS tumor growth (HR and 95% CI not defined, p = 0.41). CONCLUSIONS New or progressive ICA stenosis/occlusion was common after SRS for CSM but was not observed after SRS for GHPA, suggesting a tumor-specific mechanism unrelated to radiation dose. Pre-SRS ICA encasement or constriction increases the risk of ICA stenosis/occlusion; however, the risk of ischemic complications is very low.
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Affiliation(s)
| | - Michael J Link
- Departments of1Neurologic Surgery
- 2Otolaryngology-Head and Neck Surgery, and
| | | | | | | | - Bruce E Pollock
- Departments of1Neurologic Surgery
- 3Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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19
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Kotecha R, Yomo S, Suh JH. Response to letter regarding "Stereotactic radiosurgery for nonfunctioning pituitary adenomas: meta-analysis and International Society of Stereotactic Radiosurgery (ISRS) practice opinion". Neuro Oncol 2020; 22:1402-1403. [PMID: 32621485 DOI: 10.1093/neuonc/noaa132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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20
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Graffeo CS, Donegan D, Erickson D, Brown PD, Perry A, Link MJ, Young WF, Pollock BE. The Impact of Insulin-Like Growth Factor Index and Biologically Effective Dose on Outcomes After Stereotactic Radiosurgery for Acromegaly: Cohort Study. Neurosurgery 2020; 87:538-546. [PMID: 32267504 PMCID: PMC7426191 DOI: 10.1093/neuros/nyaa054] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 01/30/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is a safe and effective treatment for acromegaly. OBJECTIVE To improve understanding of clinical and dosimetric factors predicting biochemical remission. METHODS A single-institution cohort study of nonsyndromic, radiation-naïve patients with growth hormone-producing pituitary adenomas (GHA) having single-fraction SRS between 1990 and 2017. Exclusions were treatment with pituitary suppressive medications at the time of SRS, or <24 mo of follow-up. The primary outcome was biochemical remission-defined as normalization of insulin-like growth factor-1 index (IGF-1i) off suppression. Biochemical remission was assessed using Cox proportional hazards. Prior studies reporting IGF-1i were assessed via systematic literature review and meta-analysis using random-effect modeling. RESULTS A total of 102 patients met study criteria. Of these, 46 patients (45%) were female. The median age was 49 yr (interquartile range [IQR] = 37-59), and the median follow-up was 63 mo (IQR = 29-100). The median pre-SRS IGF-1i was 1.66 (IQR = 1.37-3.22). The median margin dose was 25 Gy (IQR = 21-25); the median estimated biologically effective dose (BED) was 169.49 Gy (IQR = 124.95-196.00). Biochemical remission was achieved in 58 patients (57%), whereas 22 patients (22%) had medication-controlled disease. Pre-SRS IGF-1i ≥ 2.25 was the strongest predictor of treatment failure, with an unadjusted hazard ratio (HR) of 0.51 (95% CI = 0.26-0.91, P = .02). Number of isocenters, margin dose, and BED predicted remission on univariate analysis, but after adjusting for sex and baseline IGF-1i, only BED remained significant-and was independently associated with outcome in continuous (HR = 1.01, 95% CI = 1.00-1.01, P = .02) and binary models (HR = 2.27, 95% CI = 1.39-5.22, P = .002). A total of 24 patients (29%) developed new post-SRS hypopituitarism. Pooled HR for biochemical remission given subthreshold IGF-1i was 2.25 (95% CI = 1.33-3.16, P < .0001). CONCLUSION IGF-1i is a reliable predictor of biochemical remission after SRS. BED appears to predict biochemical outcome more reliably than radiation dose, but confirmatory study is needed.
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Affiliation(s)
| | - Diane Donegan
- Division of Endocrinology, Indiana University, Indianapolis, Indiana
| | - Dana Erickson
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Paul D Brown
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Avital Perry
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Link
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
| | - William F Young
- Department of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Bruce E Pollock
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
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Pomeraniec IJ, Ding D, Ksendzovsky A, Liu KC. Microvascular decompression of the posterior cerebral artery for treatment of oculomotor nerve palsy. J Cerebrovasc Endovasc Neurosurg 2020; 22:85-89. [PMID: 32665915 PMCID: PMC7329561 DOI: 10.7461/jcen.2020.22.2.85] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 03/27/2016] [Accepted: 06/14/2016] [Indexed: 01/20/2023] Open
Abstract
Oculomotor nerve palsy resulting from non-aneurysmal vascular compression is extremely rare. Microvascular decompression (MVD) has been previously shown to improve oculomotor nerve palsy (ONP) secondary to arterial compression. A 71-year-old female, with a history of Cushing's disease previously treated with two transsphenoidal resections and Gamma Knife radiosurgery, presented with one year of progressive left eye diplopia and was diagnosed with a partial left oculomotor nerve palsy. We performed an orbitozygomatic craniotomy for MVD of the left posterior cerebral artery, which was found to be compressing the oculomotor nerve against the tentorium. Unfortunately, the patient's partial ONP remained unchanged at one year follow-up. The present case suggests inconsistent outcomes of MVD for ONP. Patients with prior sellar or parasellar irradiation may be less likely to benefit from this treatment approach.
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Affiliation(s)
- I Jonathan Pomeraniec
- National Institute of Neurological Disorders and Stroke, Surgical Neurology Branch, National Institutes of Health, Bethesda, MD, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville School of Medicine,, Louisville, KY, USA
| | - Alexander Ksendzovsky
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kenneth C Liu
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA
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22
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Almalki MH, Aljohani N, Alzahrani S, Almohareb O, Ahmad MM, Alrashed AA, Alshahrani F, Mahmood Buhary B. Clinical Features, Therapeutic Trends, and Outcome of Giant Prolactinomas: A Single-Center Experience Over a 12-Year Period. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2020; 13:1179551420926181. [PMID: 32547285 PMCID: PMC7273563 DOI: 10.1177/1179551420926181] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/19/2020] [Indexed: 01/06/2023]
Abstract
Background: Management of giant prolactinomas presents a different challenge than the
management of traditional prolactinomas. Objective: The aim of this study was to report the largest long-term single-center study
of giant prolactinomas to analyze their clinical features; define
epidemiological characteristics, comorbidities, complications, treatment
outcomes; and to demonstrate our experience with long-term cabergoline (CAB)
treatment of these giant tumors. Methods: A retrospective case study and clinical review of patients presenting with
giant prolactinomas in the pituitary clinic at King Fahad Medical City
(KFMC), Riyadh, Saudi Arabia, in the period between 2006 and 2018 were
included in the study. Of the charts reviewed, 33 patients (24 men; 9 women)
with age of diagnosis between 18 and 63 years (mean = 37.21 years) met the
selection criteria for giant prolactinomas. Result: The most common presenting features include headache (87.8%), visual defects
(69.7%), and hypogonadism (51.5%). The baseline means serum prolactin (PRL)
level was extremely high for both sexes (95 615.03 nmol/L), which eventually
decreased by as much as 95.4% after CAB treatment. Serum PRL concentrations
completely normalized in 11 patients and significantly reduced in 22
patients. The mean tumor volume at baseline was 42.87 cm3,
whereas the mean posttreatment tumor volume was 3.42 cm3 (no
residual tumor in 2 patients, while in others, it ranged from 0.11 to
16.7 cm3) at the last follow-up visit. The mean change in
tumor volume was 88.84%. Tumor volume decreased by an average of 92% for men
and 80.4% for women. One patient had no tumor size change with CAB (3.5 mg
thrice a week) or radiotherapy and required surgery. The response rate
(remission after medical therapy alone) in this series was 84.84%. Conclusions: Findings reinforce results from our previous study that CAB provides dramatic
clinical improvements with an excellent safety profile. The CAB should,
therefore, be considered as the primary therapy for giant prolactinomas.
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Affiliation(s)
- Mussa H Almalki
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia.,King Fahad Medical City, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Naji Aljohani
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia.,King Fahad Medical City, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Saad Alzahrani
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia.,King Fahad Medical City, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ohoud Almohareb
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Maswood M Ahmad
- Obesity, Endocrine and Metabolism Center, King Fahad Medical City (KFMC), Riyadh, Saudi Arabia
| | - Abdullah A Alrashed
- Department of Neuroimaging and Intervention, Medical Imaging Administration, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Fahad Alshahrani
- King Abdulaziz Medical City, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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23
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Ding D, Mehta GU, Patibandla MR, Lee CC, Liscak R, Kano H, Pai FY, Kosak M, Sisterson ND, Martinez-Alvarez R, Martinez-Moreno N, Mathieu D, Grills IS, Blas K, Lee K, Cifarelli CP, Katsevman GA, Lee JYK, McShane B, Kondziolka D, Lunsford LD, Vance ML, Sheehan JP. Stereotactic Radiosurgery for Acromegaly: An International Multicenter Retrospective Cohort Study. Neurosurgery 2020; 84:717-725. [PMID: 29757421 DOI: 10.1093/neuros/nyy178] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 04/05/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Stereotactic radiosurgery (SRS) is a treatment option for persistent or recurrent acromegaly secondary to a growth hormone secreting pituitary adenoma, but its efficacy is inadequately defined. OBJECTIVE To assess, in a multicenter, retrospective cohort study, the outcomes of SRS for acromegaly and determine predictors. METHODS We pooled and analyzed data from 10 participating institutions of the International Gamma Knife Research Foundation for patients with acromegaly who underwent SRS with endocrine follow-up of ≥6 mo. RESULTS The study cohort comprised 371 patients with a mean endocrine follow-up of 79 mo. IGF-1 lowering medications were held in 56% of patients who were on pre-SRS medical therapy. The mean SRS treatment volume and margin dose were 3.0 cm3 and 24.2 Gy, respectively. The actuarial rates of initial and durable endocrine remission at 10 yr were 69% and 59%, respectively. The mean time to durable remission after SRS was 38 mo. Biochemical relapse after initial remission occurred in 9%, with a mean time to recurrence of 17 mo. Cessation of IGF-1 lowering medication prior to SRS was the only independent predictor of durable remission (P = .01). Adverse radiation effects included the development of ≥1 new endocrinopathy in 26% and ≥1 cranial neuropathy in 4%. CONCLUSION SRS is a definitive treatment option for patients with persistent or recurrent acromegaly after surgical resection. There appears to be a statistical association between the cessation of IGF-1 lowering medications prior to SRS and durable remission.
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Affiliation(s)
- Dale Ding
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Gautam U Mehta
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas
| | | | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Fu-Yuan Pai
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mikulas Kosak
- 3rd Department of Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Nathaniel D Sisterson
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - David Mathieu
- Division of Neurosurgery, Centre de recherche du CHUS, University of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Inga S Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Kevin Blas
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Kuei Lee
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | | | | | - John Y K Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brendan McShane
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary Lee Vance
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia.,Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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24
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Alonso CE, Bunevicius A, Trifiletti DM, Larner J, Lee CC, Pai FY, Liscak R, Kosak M, Kano H, Sisterson ND, Mathieu D, Lunsford LD, Sheehan JP. Safety and efficacy of repeat radiosurgery for acromegaly: an International Multi-Institutional Study. J Neurooncol 2019; 145:301-307. [PMID: 31541405 DOI: 10.1007/s11060-019-03296-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 09/17/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE Surgical resection is the first line treatment for growth hormone (GH) secreting tumors. Stereotactic radiosurgery (SRS) is recommended for patients who do not achieve endocrine remission after resection. The purpose of this study was to evaluate safety and efficacy of repeat radiosurgery for acromegaly. METHODS Three hundred and ninety-eight patients with acromegaly treated with the Gamma Knife radiosurgery (Elekta AB, Stockholm) were identified from the International Gamma Knife Research Foundation database. Among these, 21 patients underwent repeated SRS with sufficient endocrine follow-up and 18 patients had sufficient imaging follow-up. Tumor control was defined as lack of adenoma progression on imaging. Endocrine remission was defined as a normal IGF-1 concentration while off medical therapy. RESULTS Median time from initial SRS to repeat SRS was 5.0 years. The median imaging and endocrine follow-up duration after repeat SRS was 3.4 and 3.8 years, respectively. The median initial marginal dose was 17 Gy, and the median repeat marginal dose was 23 Gy. Of the 18 patients with adequate imaging follow up, 15 (83.3%) patients had tumor control and of 21 patients with endocrine follow-up, 9 (42.9%) patients had endocrine remission at last follow-up visit. Four patients (19.0%) developed new deficits after repeat radiosurgery. Of these, 3 patients had neurologic deficits and 1 patient had endocrine deficit. CONCLUSIONS Repeat radiosurgery for persistent acromegaly offers a reasonable benefit to risk profile for this challenging patient cohort. Further studies are needed to identify patients best suited for this type of approach.
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Affiliation(s)
- Clayton E Alonso
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Adomas Bunevicius
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - James Larner
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA, USA
| | - Cheng-Chia Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Fu-Yuan Pai
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Mikulas Kosak
- 3rd Department of Medicine, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Hideyuki Kano
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - David Mathieu
- Division of Neurosurgery, Centre de Recherche du CHUS, University of Sherbrooke, Sherbrooke, QC, Canada
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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25
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Ding ZQ, Zhang SF, Wang QH. Neuroendoscopic and microscopic transsphenoidal approach for resection of nonfunctional pituitary adenomas. World J Clin Cases 2019; 7:1591-1598. [PMID: 31367618 PMCID: PMC6658379 DOI: 10.12998/wjcc.v7.i13.1591] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/29/2019] [Accepted: 05/01/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Nonfunctional pituitary adenoma is a common type of pituitary adenoma, which can lead to headache, visual field disturbance, and cranial nerve damage due to increased tumor volume. Neuroendoscopic and microscopic transsphenoidal approaches have been widely used in the resection of nonfunctional pituitary adenomas. However, the clinical efficacy in neuroendoscopic and microscopic surgery is still controversial.
AIM To explore the clinical efficacy of neuroendoscopic and microscopic transsphenoidal approach for resection of nonfunctional pituitary adenomas.
METHODS We retrospectively analyzed 251 patients with nonfunctional pituitary adenomas; 138 underwent neuroendoscopic surgery via transsphenoidal approach, and 113 underwent microscopic surgery via transsphenoidal approach between July 2010 and September 2015. All patients were followed up for > 6 mo. Gender, age, course of disease, tumor diameter, tumor location, and percentage of patients with headache, visual impairment, sexual dysfunction, and menstrual disorders were contrasted between the two groups to compare the difference of preoperative data. Cure rate, symptom improvement rate, recurrence rate, the postoperative hospital stay, operating time, intraoperative blood loss, and the incidence of postoperative complications were compared in order to evaluate the advantages and disadvantages of neuroendoscopic and microscopic surgery.
RESULTS There was no significant difference in cure rate, symptom improvement rate, and recurrence rate between neuroendoscopy group and microscopy group (82.6% vs 85.8%, P > 0.05; 90.6% vs 93.8%, P > 0.05; 5.1% vs 9.7%, P > 0.05). In the neuroendoscopy group, the postoperative hospital stay was 8.4 ± 0.6 d; operating time was 167.2 ± 9.6 min; intraoperative blood loss was 83.4 ± 9.3 mL, and the rates of diabetes insipidus and electrolyte imbalance were 4.3% and 8.0%, respectively. The corresponding results in the microscopic group were 11.2 ± 0.6 d, 199.7 ± 9.3 min, 138.8 ± 13.6 mL, and 32.7% and 20.4%, respectively. There were significant differences in postoperative hospital stay, operating time, intraoperative blood loss, and the rates of diabetes insipidus and electrolyte imbalance between the two groups (P < 0.05).
CONCLUSION Neuroendoscopic and microscopic transsphenoidal approaches have similar clinical efficacy for the resection of nonfunctional pituitary adenomas. Neuroendoscopic surgery reduces operating time, intraoperative bleeding, postoperative recovery, and complications.
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Affiliation(s)
- Zhi-Quan Ding
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou 510282, Guangdong Province, China
| | - Sheng-Fan Zhang
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou 510282, Guangdong Province, China
| | - Qing-Hua Wang
- Department of Neurosurgery, Zhujiang Hospital, Southern Medical University, The National Key Clinical Specialty, The Engineering Technology Research Center of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou 510282, Guangdong Province, China
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26
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Jakobsson Ung E, Olofsson AC, Björkman I, Hallén T, Olsson DS, Ragnarsson O, Skoglund T, Jakobsson S, Johannsson G. The pre- and postoperative illness trajectory in patients with pituitary tumours. Endocr Connect 2019; 8:878-886. [PMID: 31176303 PMCID: PMC6599075 DOI: 10.1530/ec-19-0202] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/06/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Experiences and need of support during surgery and start of replacement therapy in patients with pituitary tumours are highly unknown. This study aimed at exploring patient experiences during pre- and postoperative care and recovery after pituitary surgery in patients with a pituitary tumour. METHODS Within a qualitative study design, 16 consecutive patients who underwent surgery for pituitary tumours were repeatedly interviewed. In total, 42 interviews were performed before and after surgery. Analysis was performed using qualitative interpretation. RESULTS Suffering a pituitary tumour was overwhelming for many patients and struggling with existential issues was common. Patients expressed loneliness and vulnerability before and after surgery. How professionals handled information in connection with diagnosis greatly affected the patients. Other patients with the same diagnosis were experienced as the greatest support. Normalisation of bodily symptoms and relationships with others were reported during postoperative recovery. However, a fear that the tumour would return was present. CONCLUSIONS Patients with pituitary tumours need structured support, including peer support, which acknowledges physical, cognitive as well as emotional and existential concerns. Information related to diagnosis and surgery should be adapted in relation to the loneliness and the existential seriousness of the situation. Care and support for patients with pituitary tumours should preferably be organised based on continuity and an unbroken care pathway from the first pre-operative evaluation through to postoperative care and the start of a life-long endocrine treatment and tumour surveillance.
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Affiliation(s)
- Eva Jakobsson Ung
- Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Ida Björkman
- Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Tobias Hallén
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Daniel S Olsson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas Skoglund
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Neuroscience and Physiology, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Sofie Jakobsson
- Institute of Health and Care Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Correspondence should be addressed to G Johannsson:
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27
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Jacob J, Feuvret L, Mazeron JJ, Simon JM, Canova CH, Riet FG, Blais E, Jenny C, Maingon P. Radioterapia dei tumori cerebrali primitivi dell’adulto. Neurologia 2019. [DOI: 10.1016/s1634-7072(18)41587-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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28
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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.
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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.
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29
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Nicholas SE, Salvatori R, Quinones-Hinojosa A, Redmond K, Gallia G, Lim M, Rigamonti D, Brem H, Kleinberg L. Deferred Radiotherapy After Debulking of Non-functioning Pituitary Macroadenomas: Clinical Outcomes. Front Oncol 2019; 8:660. [PMID: 30687636 PMCID: PMC6335347 DOI: 10.3389/fonc.2018.00660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 12/13/2018] [Indexed: 11/13/2022] Open
Abstract
Background: To describe the outcome for a cohort of patients with non-functioning pituitary macroadenomas (NFPMA), managed by debulking surgery with radiation therapy delayed until progression. Methods: Two hundred and sixty-seven patients were treated surgically for pituitary tumors at our institution between 1997 and 2005. One hundred and twenty-six patients met the inclusion criteria of NFPMA. They were followed for at least 2 years. Results: At presentation, 58% of patients had objectively decreased visual function, 66% had endocrine abnormalities, and 46% had headaches. Of the entire cohort, 75% of tumors abutted the optic chiasm and 87% had suprasellar extension. Over a median follow up of 112 months from surgery, 52% of patients had evidence of radiographic tumor progression, and 39% required additional treatment. There was a significant difference freedom from progression and in the number of patients receiving additional treatment with preoperative adenoma size of < 2 vs. ≥2 cm (p < 0.05). Conclusion: Close observation with radiation therapy delayed until the time of progression is an appropriate option for patients presenting with initial adenoma size < 2 cm, and can be considered for those with initial sizes up to 4 cm, as the majority of patients do not require further intervention for 10 or more years, thereby meaningfully postponing the risks of radiotherapy.
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Affiliation(s)
- Sarah E Nicholas
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Roberto Salvatori
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Alfredo Quinones-Hinojosa
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kristin Redmond
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Gary Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael Lim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniele Rigamonti
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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30
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Abstract
INTRODUCTION Cushing's disease is a rare systemic and disabling disease due to oversecretion of adrenocorticotrophic hormone (ACTH) resulting in excess cortisol levels. Diagnosis and treatment are difficult; despite the availability of various pharmaceutical treatment options, there is an ongoing, unmet need for even more effective treatment. AREAS COVERED The present review aims at providing an overview of available drugs and presenting new developments. Focusing on the pituitary as a target, the review covers compounds targeting pituitary cell signaling or cell cycle control such as heat shock protein inhibitors (e.g. silibinin), histone deacetylase inhibitors (trichostatin A, vorinostat), kinase inhibitors (gefitinib, seliciclib), and others (such as triptolide, AT-101). Levoketoconazole and osilodrostat are in clinical testing and inhibit steroidogenesis. Blockade of ACTH receptor binding at the adrenal level is explained as a theoretical drug target. Inhibition of binding of the glucocorticoid receptor in the peripheral tissue plays a minor role due to its lack of biomonitoring options. EXPERT OPINION In our opinion, further research and drug development of pituitary-directed targets are necessary. Combination therapies may exert synergistic effects and allow for smaller and better tolerated doses, but more experience and data are needed to guide such treatment schemes.
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Affiliation(s)
- Sylvère Störmann
- a Medizinische Klinik und Poliklinik IV , Klinikum der Universität München , München , Germany
| | - Jochen Schopohl
- a Medizinische Klinik und Poliklinik IV , Klinikum der Universität München , München , Germany
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31
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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]
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32
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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.
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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.
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Abstract
Non-functioning pituitary carcinomas (NFPC) are defined as tumours of adenophyseal origin with craniospinal or systemic dissemination, with the absence of a hormonal hypersecretion syndrome. These are a histologically heterogenous group of tumours, comprising gonadotroph, null cell, "silent" tumours of corticotroph, somatotroph or lactotroph cell lineages as well as plurihormonal Pit-1 tumours. NFPC are exceedingly rare, and hence few cases have been described. This review has identified 38 patients with NFPC reported in the literature. Recurrent invasive non-functioning pituitary adenomas (NFPA) were observed in a majority of patients. Various factors have been identified as markers of the potential for aggressive behaviour, including rapid tumour growth, growth after radiotherapy, gain or shift of hormone secretion and raised proliferative markers. Typically, there is a latency of several years from the original presentation with an NFPA to identification of metastases and only 5 cases reported with rapidly progressive malignant disease within 1 month of presentation. Therapeutic options include debulking surgery, radiation therapy and chemotherapy with temozolomide recommended as first line systemic treatment. Although long-term survivors are described, prognosis remains generally very poor (median survival 8 months). Improvements in molecular tumour profiling may assist in predicting tumour behaviour, guide therapeutic choices and identify novel therapies.
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Affiliation(s)
- Nèle Lenders
- Garvan Institute of Medical Research, Sydney, Australia
- Department of Endocrinology, St Vincent's Hospital, University of New South Wales, Sydney, Australia
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Ann McCormack
- Garvan Institute of Medical Research, Sydney, Australia.
- Department of Endocrinology, St Vincent's Hospital, University of New South Wales, Sydney, Australia.
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34
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Perry A, Graffeo CS, Marcellino C, Pollock BE, Wetjen NM, Meyer FB. Pediatric Pituitary Adenoma: Case Series, Review of the Literature, and a Skull Base Treatment Paradigm. J Neurol Surg B Skull Base 2018; 79:91-114. [PMID: 29404245 DOI: 10.1055/s-0038-1625984] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Pediatric pituitary adenoma is a rare skull base neoplasm, accounting for 3% of all intracranial neoplasms in children and 5% of pituitary adenomas. Compared with pituitary tumors in adults, secreting tumors predominate and longer disease trajectories are expected due to the patient age resulting in a natural history and treatment paradigm that is complex and controversial. Objectives The aims of this study were to describe a large, single-institution series of pediatric pituitary adenomas with extensive long-term follow-up and to conduct a systematic review examining outcomes after pituitary adenoma surgery in the pediatric population. Methods The study cohort was compiled by searching institutional pathology and operative reports using diagnosis and site codes for pituitary and sellar pathology, from 1956 to 2016. Systematic review of the English language literature since 1970 was conducted using PubMed, MEDLINE, Embase, and Google Scholar. Results Thirty-nine surgically managed pediatric pituitary adenomas were identified, including 15 prolactinomas, 14 corticotrophs, 7 somatotrophs, and 4 non-secreting adenomas. All patients underwent transsphenoidal resection (TSR) as the initial surgical treatment. Surgical cure was achieved in 18 (46%); 21 experienced recurrent/persistent disease, with secondary treatments including repeat surgery in 10, radiation in 14, adjuvant pharmacotherapy in 11, and bilateral adrenalectomy in 3. At the last follow-up (median 87 months, range 3-581), nine remained with recurrent/persistent disease (23%). Thirty-seven publications reporting surgical series of pediatric pituitary adenomas were included, containing 1,284 patients. Adrenocorticotropic hormone (ACTH)-secreting tumors were most prevalent (43%), followed by prolactin (PRL)-secreting (37%), growth hormone (GH)-secreting (12%), and nonsecreting (7%). Surgical cure was reported in 65%. Complications included pituitary insufficiency (23%), permanent visual dysfunction (6%), chronic diabetes insipidus (DI) (3%), and postoperative cerebrospinal fluid (CSF) leak (4%). Mean follow-up was 63 months (range 0-240), with recurrent/persistent disease reported in 18% at the time of last follow-up. Conclusion Pediatric pituitary adenomas are diverse and challenging tumors with complexities far beyond those encountered in the management of routine adult pituitary disease, including nuanced decision-making, a technically demanding operative environment, high propensity for recurrence, and the potentially serious consequences of hypopituitarism with respect to fertility and growth potential in a pediatric population. Optimal treatment requires a high degree of individualization, and patients are most likely to benefit from consolidated, multidisciplinary care in highly experienced centers.
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Affiliation(s)
- Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, United States
| | | | | | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, United States
| | - Nicholas M Wetjen
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, United States
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester Minnesota, United States
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Raverot G, Burman P, McCormack A, Heaney A, Petersenn S, Popovic V, Trouillas J, Dekkers OM. European Society of Endocrinology Clinical Practice Guidelines for the management of aggressive pituitary tumours and carcinomas. Eur J Endocrinol 2018; 178:G1-G24. [PMID: 29046323 DOI: 10.1530/eje-17-0796] [Citation(s) in RCA: 332] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pituitary tumours are common and easily treated by surgery or medical treatment in most cases. However, a small subset of pituitary tumours does not respond to standard medical treatment and presents with multiple local recurrences (aggressive pituitary tumours) and in rare occasion with metastases (pituitary carcinoma). The present European Society of Endocrinology (ESE) guideline aims to provide clinical guidance on diagnosis, treatment and follow-up in aggressive pituitary tumours and carcinomas. METHODS We decided upfront, while acknowledging that literature on aggressive pituitary tumours and carcinomas is scarce, to systematically review the literature according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The review focused primarily on first- and second-line treatment in aggressive pituitary tumours and carcinomas. We included 14 single-arm cohort studies (total number of patients = 116) most on temozolomide treatment (n = 11 studies, total number of patients = 106). A positive treatment effect was seen in 47% (95% CI: 36-58%) of temozolomide treated. Data from the recently performed ESE survey on aggressive pituitary tumours and carcinomas (165 patients) were also used as backbone for the guideline. SELECTED RECOMMENDATION: (i) Patients with aggressive pituitary tumours should be managed by a multidisciplinary expert team. (ii) Histopathological analyses including pituitary hormones and proliferative markers are needed for correct tumour classification. (iii) Temozolomide monotherapy is the first-line chemotherapy for aggressive pituitary tumours and pituitary carcinomas after failure of standard therapies; treatment evaluation after 3 cycles allows identification of responder and non-responder patients. (iv) In patients responding to first-line temozolomide, we suggest continuing treatment for at least 6 months in total. Furthermore, the guideline offers recommendations for patients who recurred after temozolomide treatment, for those who did not respond to temozolomide and for patients with systemic metastasis.
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Affiliation(s)
- Gerald Raverot
- Fédération d'Endocrinologie, Centre de Référence des Maladies Rares Hypophysaires HYPO, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
- INSERM U1052, CNRS UMR5286, Cancer Research Centre of Lyon, Lyon, France
| | - Pia Burman
- Department of Endocrinology, Skane University Hospital Malmö, University of Lund, Lund, Sweden
| | - Ann McCormack
- Garvan Institute, Sydney, Australia
- Department of Endocrinology, St Vincent's Hospital, University of New South Wales, Sydney, Australia
| | - Anthony Heaney
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Vera Popovic
- Medical Faculty, University Belgrade, Belgrade, Serbia
| | - Jacqueline Trouillas
- Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
- Centre de Pathologie et de Biologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Olaf M Dekkers
- Departments of Internal Medicine (Section Endocrinology) & Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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Microsurgical versus endoscopic transsphenoidal resection for acromegaly: a systematic review of outcomes and complications. Acta Neurochir (Wien) 2017; 159:2193-2207. [PMID: 28913667 DOI: 10.1007/s00701-017-3318-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/28/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE The aim of this systematic review is to evaluate the long-term endocrine outcomes and postoperative complications following endoscopic vs. microscopic transsphenoidal resection (TSR) for the treatment of acromegaly. METHODS A literature review was performed, and studies with at least five patients who underwent TSR for acromegaly, reporting biochemical remission criteria and long-term remission outcomes were included. Data extracted from each study included surgical technique, perioperative complications, biochemical remission criteria, and long-term remission outcomes. RESULTS Fifty-two case series from 1976 to 2016 met the inclusion criteria, comprising 4375 patients. Thirty-six reports were microsurgical (n = 3144) and 13 were endoscopic (n = 940). Three studies compared microsurgical (n = 111) to endoscopic TSR outcomes (n = 180). The overall initial and long-term remission rates were 58.2 vs. 57.4% and 69.2 vs. 70.2% for the microsurgical and endoscopic groups, respectively. For microadenomas, the initial and long-term remission rates were 77.6 vs. 82.2% and 76.9 vs. 73.5% for microsurgical and endoscopic approaches, respectively. For macroadenomas, the initial and long-term remission rates were 46.9 vs. 60.0% and 40.2 vs. 61.5% for microsurgical and endoscopic approaches, respectively. The rates of postoperative CSF leak were 3.0 vs. 2.3% for the microscopic and endoscopic groups, respectively. The rates of hypopituitarism and transient diabetes insipidus were 6.7 vs. 6.4% and 9.0 vs. 7.8% for the microscopic and endoscopic groups, respectively. CONCLUSIONS Both endoscopic and microsurgical approaches for TSR of growth hormone-secreting adenomas are viable treatment options for patients with acromegaly, and yield similarly high rates of remission under the most current consensus criteria.
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Prognostic significance of corticotroph staining in radiosurgery for non-functioning pituitary adenomas: a multicenter study. J Neurooncol 2017; 135:67-74. [PMID: 28913674 DOI: 10.1007/s11060-017-2520-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/29/2017] [Indexed: 10/18/2022]
Abstract
Silent corticotroph staining pituitary adenoma (SCA) represents an uncommon subset of Non-Functioning adenomas (NFAs), hypothesized to be more locally aggressive. In this retrospective multicenter study, we investigate the safety and effectiveness of Stereotactic Radiosurgery (SRS) in patients with SCA compared with other non-SCA NFA's. Eight centers participating in the International Gamma-Knife Research Foundation (IGKRF) contributed to this study. Outcomes of 50 patients with confirmed SCAs and 307 patients with confirmed non-SCA NFA's treated with SRS were evaluated. Groups were matched. SCA was characterized by a lack of clinical evidence of Cushing disease, yet with positive immunostaining for corticotroph. Median age was 55.2 years (13.7-87). All patients underwent at least one trans-sphenoidal tumor resection prior to SRS. SRS parameters were comparable as well. Median follow-up 40 months (6-163). Overall tumor control rate (TCR) 91.2% (n = 280). In the SCA group, TCR were 82% (n = 41) versus 94.1% (n = 289) for the control-NFA (p = 0.0065). The SCA group showed a significantly higher incidence of new post-SRS visual deficit (p < 0.0001) assigned to tumor progression and growth, and post-SRS weakness and fatigue (p < 0.0001). In univariate and multivariate analysis, only the status of silent corticotroph staining (p = 0.005, p = 0.009 respectively) and margin dose (p < 0.0005, p = 0.0037 respectively) significantly influenced progression rate. A margin dose of ≥17 Gy was noted to influence the adenoma progression rate in the entire cohort (p = 0.003). Silent corticotroph staining represents an independent factor for adenoma progression and hypopituitarism after SRS. A higher margin dose may convey a greater chance of TCR.
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Zhou K, Fan YD, Duysenbi S, Wu PF, Feng ZH, Qian Z, Zhang TR. siRNA-mediated silencing of bFGF gene inhibits the proliferation, migration, and invasion of human pituitary adenoma cells. Tumour Biol 2017; 39:1010428317704805. [PMID: 28656882 DOI: 10.1177/1010428317704805] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Kai Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, P.R. China
| | - Yan-Dong Fan
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, P.R. China
| | - Serick Duysenbi
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, P.R. China
| | - Peng-Fei Wu
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, P.R. China
| | - Zhao-Hai Feng
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, P.R. China
| | - Zheng Qian
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, P.R. China
| | - Ting-Rong Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, P.R. China
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Raper DM, Ding D, Evans E, Starke RM, Crowley RW, Liu KC, Oldfield EH, Jane JA. Clinical Features, Management Considerations and Outcomes in Case Series of Patients with Parasellar Intracranial Aneurysms Undergoing Anterior Skull Base Surgery. World Neurosurg 2017; 99:424-432. [DOI: 10.1016/j.wneu.2016.11.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 11/28/2016] [Accepted: 11/29/2016] [Indexed: 10/20/2022]
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40
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Przybylowski CJ, Dallapiazza RF, Williams BJ, Pomeraniec IJ, Xu Z, Payne SC, Laws ER, Jane JA. Primary versus revision transsphenoidal resection for nonfunctioning pituitary macroadenomas: matched cohort study. J Neurosurg 2017; 126:889-896. [DOI: 10.3171/2016.3.jns152735] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The object of this study was to compare the outcomes of primary and revision transsphenoidal resection (TSR) of nonfunctioning pituitary macroadenomas (NFPMAs) using endoscopic methods.
METHODS
The authors retrospectively reviewed the records of 287 consecutive patients who had undergone endoscopic endonasal TSR for NFPMAs at their institution in the period from 2005 to 2011. Fifty patients who had undergone revision TSR were retrospectively matched for age, sex, and duration of follow-up to 46 patients who had undergone primary TSR. Medical and surgical complications were documented, and Kaplan-Meier analysis was performed to assess rates of radiological progression-free survival (PFS).
RESULTS
The median follow-up periods were 45 and 46 months for the primary and revision TSR groups, respectively. There were no significant differences between the primary and revision groups in rates of new neurological deficit (0 in each), vascular injury (2% vs 0), postoperative CSF leak (6% vs 2%), transient diabetes insipidus (DI; 15% vs 12%), chronic DI (2% vs 2%), chronic sinusitis (4% vs 6%), meningitis (2% vs 2%), epistaxis (7% vs 0), or suprasellar hematoma formation (0 vs 2%). However, patients who underwent primary TSR had significantly higher rates of syndrome of inappropriate antidiuretic hormone (SIADH; 17% vs 4%, p = 0.04). Patients who underwent primary operations also had significantly higher rates of gross-total resection (GTR; 63% vs 28%, p < 0.01) and significantly lower rates of adjuvant radiotherapy (13% vs 42%, p < 0.01). Radiological PFS rates were similar at 2 years (98% vs 96%) and 5 years (87% vs 80%, p = 0.668, log-rank test).
CONCLUSIONS
Patients who underwent primary TSR of NFPMAs experienced higher rates of SIADH than those who underwent revision TSR. Patients who underwent revision TSR were less likely to have GTR of their tumor, although they still had a PFS rate similar to that in patients who underwent primary TSR. This finding may be attributable to an increased rate of adjuvant radiation treatment to subtotally resected tumors in the revision TSR group.
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Affiliation(s)
| | | | | | | | | | - Spencer C. Payne
- 2Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Edward R. Laws
- 3Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Farrell CJ, Nyquist GG, Farag AA, Rosen MR, Evans JJ. Principles of Pituitary Surgery. Otolaryngol Clin North Am 2016; 49:95-106. [PMID: 26614830 DOI: 10.1016/j.otc.2015.09.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Since the description of a transnasal approach for treatment of pituitary tumors, transsphenoidal surgery has undergone continuous development. Hirsch developed a lateral endonasal approach before simplifying it to a transseptal approach. Cushing approached pituitary tumors using a transsphenoidal approach but transitioned to the transcranial route. Transsphenoidal surgery was not "rediscovered" until Hardy introduced the surgical microscope. An endoscopic transsphenoidal approach for pituitary tumors has been reported and further advanced. We describe the principles of pituitary surgery including the key elements of surgical decision making and discuss the technical nuances distinguishing the endoscopic from the microscopic approach.
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Affiliation(s)
- Christopher J Farrell
- Department of Neurological Surgery, Thomas Jefferson University, 909 Walnut Street, 2nd Floor, Philadelphia, PA 19107, USA.
| | - Gurston G Nyquist
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander A Farag
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marc R Rosen
- Department of Otolaryngology, Thomas Jefferson University, Philadelphia, PA, USA
| | - James J Evans
- Department of Neurological Surgery, Thomas Jefferson University, 909 Walnut Street, 2nd Floor, Philadelphia, PA 19107, USA
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Delannes M, Latorzeff I, Chand ME, Huchet A, Dupin C, Colin P. [Radiotherapy of benign intracranial tumors]. Cancer Radiother 2016; 20 Suppl:S88-95. [PMID: 27523417 DOI: 10.1016/j.canrad.2016.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Most of the benign intracranial tumors are meningiomas, vestibular schwannomas, pituitary adenomas, craniopharyngiomas, and glomus tumors. Some of them grow very slowly, and can be observed without specific treatment, especially if they are asymptomatic. Symptomatic or growing tumors are treated by surgery, which is the reference treatment. When surgery is not possible, due to the location of the lesion, or general conditions, radiotherapy can be applied, as it is if there is a postoperative growing residual tumor, or a local relapse. Indications have to be discussed in polydisciplinary meetings, with precise evaluation of the benefit and risks of the treatments. The techniques to be used are the most modern ones, as multimodal imaging and image-guided radiation therapy. Stereotactic treatments, using fractionated or single doses depending on the size or the location of the tumors, are commonly realized, to avoid as much a possible the occurrence of late side effects.
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Affiliation(s)
- M Delannes
- Service de radiothérapie, institut Claudius-Regaud, IUCT-Oncopole, 1, avenue Irène-Joliot-Curie, 31059 Toulouse cedex 9, France.
| | - I Latorzeff
- Service de radiothérapie, groupe Oncorad Garonne, clinique Pasteur, bâtiment Atrium, 1, rue de la Petite-Vitesse, 31300 Toulouse, France; Centre régional de radiochirurgie stéréotaxique, CHU Rangueil, avenue Jean-Poulhès, 31052 Toulouse cedex, France
| | - M E Chand
- Service de radiothérapie, centre Antoine-Lacassagne, 33, avenue de Valombrose, 06189 Nice cedex 2, France
| | - A Huchet
- Centre de radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France
| | - C Dupin
- Centre de radiothérapie, hôpital Haut-Lévêque, CHU de Bordeaux, avenue de Magellan, 33604 Pessac cedex, France
| | - P Colin
- Service de radiothérapie, polyclinique Courlancy, 38 bis, rue de Courlancy, 51100 Reims, France
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Vieira Neto L, Boguszewski CL, Araújo LAD, Bronstein MD, Miranda PAC, Musolino NRDC, Naves LA, Vilar L, Ribeiro-Oliveira Júnior A, Gadelha MR. A review on the diagnosis and treatment of patients with clinically nonfunctioning pituitary adenoma by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:374-90. [PMID: 27533614 PMCID: PMC10118716 DOI: 10.1590/2359-3997000000179] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/04/2016] [Indexed: 04/22/2023]
Abstract
Clinically nonfunctioning pituitary adenomas (NFPA) are the most common pituitary tumors after prolactinomas. The absence of clinical symptoms of hormonal hypersecretion can contribute to the late diagnosis of the disease. Thus, the majority of patients seek medical attention for signs and symptoms resulting from mass effect, such as neuro-ophthalmologic symptoms and hypopituitarism. Other presentations include pituitary apoplexy or an incidental finding on imaging studies. Mass effect and hypopituitarism impose high morbidity and mortality. However, early diagnosis and effective treatment minimizes morbidity and mortality. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism is to provide a review of the diagnosis and treatment of patients with NFPA, emphasizing that the treatment should be performed in reference centers. This review is based on data published in the literature and the authors' experience. Arch Endocrinol Metab. 2016;60(4):374-90.
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Affiliation(s)
- Leonardo Vieira Neto
- Universidade Federal do Rio de Janeiro, Brasil; Hospital Federal da Lagoa, Brasil
| | | | | | | | | | | | | | | | | | - Mônica R. Gadelha
- Universidade Federal do Rio de Janeiro, Brasil; Instituto Estadual do Cérebro Paulo Niemeyer, Brasil
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44
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Øystese KA, Evang JA, Bollerslev J. Non-functioning pituitary adenomas: growth and aggressiveness. Endocrine 2016; 53:28-34. [PMID: 27066792 DOI: 10.1007/s12020-016-0940-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 03/23/2016] [Indexed: 10/22/2022]
Abstract
Pituitary adenomas (PAs) are common, comprising approximately one third of all intracranial tumors. Non-functioning pituitary adenomas (NFPAs) are the most common PAs. Although usually benign, the NFPAs represent therapeutic challenges because of their location close to the optic chiasm and nerves, and the proximity to the pituitary gland. The therapeutic alternatives are surgery and radiation. To date there is no effective medical treatment. NFPAs are classified according to different modalities, but there are no reliable marker of aggressiveness to guide the clinician in monitoring the patient. More information on growth patterns with constituent biological markers are needed to tailor the care of this patient group. Studies characterizing the membrane receptors of NFPAs have shown promising results, which may give rise to the development of medical treatment.
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Affiliation(s)
- Kristin Astrid Øystese
- Department of Specialized Endocrinology, Rikshospitalet, Oslo University Hospital, Pb 4950 Nydalen, 0424, Oslo, Norway.
- Faculty of Medicine, University of Oslo, Klaus Torgårdsvei 3, 0372, Oslo, Norway.
| | - Johan Arild Evang
- Department of Specialized Endocrinology, Rikshospitalet, Oslo University Hospital, Pb 4950 Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, University of Oslo, Klaus Torgårdsvei 3, 0372, Oslo, Norway
| | - Jens Bollerslev
- Department of Specialized Endocrinology, Rikshospitalet, Oslo University Hospital, Pb 4950 Nydalen, 0424, Oslo, Norway
- Faculty of Medicine, University of Oslo, Klaus Torgårdsvei 3, 0372, Oslo, Norway
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Kim MY, Kim JH, Oh YK, Kim E. Long-term outcomes of surgery and radiotherapy for secreting and non-secreting pituitary adenoma. Radiat Oncol J 2016; 34:121-7. [PMID: 27306775 PMCID: PMC4938346 DOI: 10.3857/roj.2016.01683] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 03/14/2016] [Accepted: 03/31/2016] [Indexed: 11/12/2022] Open
Abstract
Purpose: To investigate treatment outcome and long term complication after surgery and radiotherapy (RT) for pituitary adenoma. Materials and Methods: From 1990 to 2009, 73 patients with surgery and RT for pituitary adenoma were analyzed in this study. Median age was 51 years (range, 25 to 71 years). Median tumor size was 3 cm (range, 1 to 5 cm) with suprasellar (n = 21), cavernous sinus extension (n = 14) or both (n = 5). Hormone secreting tumor was diagnosed in 29 patients; 16 patients with prolactin, 12 patients with growth hormone, and 1 patient with adrenocorticotrophic hormone. Impairment of visual acuity or visual field was presented in 33 patients at first diagnosis. Most patients (n = 64) received RT as postoperative adjuvant setting. Median RT dose was 45 Gy (range, 45 to 59.4 Gy). Results: Median follow-up duration was 8 years (range, 3 to 22 years). In secreting tumors, hormone normalization rate was 55% (16 of 29 patients). For 25 patients with evaluable visual field and visual acuity test, 21 patients (84%) showed improvement of visual disturbance after treatment. The 10-year tumor control rate for non-secreting and secreting adenoma was 100% and 58%, respectively (p < 0.001). Progression free survival rate at 10 years was 98%. Only 1 patient experienced endocrinological recurrence. Following surgery, 60% (n = 44) suffered from pituitary function deficit. Late complication associated with RT was only 1 patient, who developed cataract. Conclusion: Surgery and RT are very effective and safe in hormonal and tumor growth control for secreting and non-secreting pituitary adenoma.
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Affiliation(s)
- Mi Young Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Young Kee Oh
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - El Kim
- Department of Neurosurgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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Fu P, He YS, Cen YC, Huang Q, Guo KT, Zhao HY, Xiang W. Microneurosurgery and subsequent gamma knife radiosurgery for functioning pituitary macroadenomas or giant adenomas: One institution’s experience. Clin Neurol Neurosurg 2016; 145:8-13. [DOI: 10.1016/j.clineuro.2016.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 03/22/2016] [Accepted: 03/26/2016] [Indexed: 10/22/2022]
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47
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Lin AL, Sum MW, DeAngelis LM. Is there a role for early chemotherapy in the management of pituitary adenomas? Neuro Oncol 2016; 18:1350-6. [PMID: 27106409 DOI: 10.1093/neuonc/now059] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/16/2016] [Indexed: 12/25/2022] Open
Abstract
Pituitary adenomas are benign intracranial neoplasms that are frequently well-controlled with standard treatments that include surgical resection, radiotherapy, and agents that modulate hormonal excess. Unfortunately, a subset of patients remains uncontrolled or develops complications from these interventions. For these patients, chemotherapy is an additional treatment option that could improve outcomes. Temozolomide is an oral chemotherapy with a favorable side-effect profile that has shown activity against pituitary adenomas. Its non-overlapping toxicity and ability to induce rapid tumor regression renders it a potentially important adjunctive treatment. In patients with tumors that cannot be optimally addressed with standard treatments, there may be a role for early initiation of temozolomide.
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Affiliation(s)
- Andrew L Lin
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.L.L., L.M.D.A.)
| | - Melissa W Sum
- Division of Endocrinology, Columbia University Medical Center, New York, New York (M.W.S.)
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.L.L., L.M.D.A.)
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48
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Bauman CA, Milligan JD, Labreche T, Riva JJ. Nonfunctioning pituitary macroadenoma: a case report from the patient perspective. Chiropr Man Therap 2016; 24:12. [PMID: 27069570 PMCID: PMC4827193 DOI: 10.1186/s12998-016-0093-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 03/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nonfunctioning pituitary macroadenoma (NFPA) is a tumour of the endocrine system that is virtually always benign and can be difficult to detect. This case report is presented from the patient's perspective to highlight experiences that led to the eventual diagnosis of this condition. CASE PRESENTATION A 48 year-old male experienced prolonged and unexplained reduced athletic performance worsening over five years. The patient reported decreased libido, which initiated a testosterone blood test. This confirmed reduced testosterone levels and resulted in an endocrinology referral. A subsequent dynamic contrast MRI of the pituitary region revealed a mass. The most frequent symptoms of NFPA are visual field defects, headaches and features of hypopituitarism (includes fatigue, dizziness, dry skin, irregular periods in women and sexual dysfunction in men). CONCLUSION Clinicians should consider this differential diagnosis in middle-aged athletes with diminished athletic performance from an unknown cause, test visual fields and inquire if symptoms of headaches or hypopituitarism are present.
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Affiliation(s)
- Craig A Bauman
- Department of Family Medicine, McMaster University, Hamilton, ON Canada ; The Centre for Family Medicine Family Health Team, 25 Joseph Street, Kitchener, ON Canada N2G 4X6
| | - James D Milligan
- Department of Family Medicine, McMaster University, Hamilton, ON Canada ; The Centre for Family Medicine Family Health Team, 25 Joseph Street, Kitchener, ON Canada N2G 4X6
| | - Tammy Labreche
- School of Optometry and Vision Science, University of Waterloo, Waterloo, ON Canada
| | - John J Riva
- Department of Family Medicine, McMaster University, Hamilton, ON Canada ; Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON Canada
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Cohen-Inbar O, Ramesh A, Xu Z, Vance ML, Schlesinger D, Sheehan JP. Gamma knife radiosurgery in patients with persistent acromegaly or Cushing's disease: long-term risk of hypopituitarism. Clin Endocrinol (Oxf) 2016; 84:524-31. [PMID: 26341248 DOI: 10.1111/cen.12938] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/24/2015] [Accepted: 08/31/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION For patient with a recurrent or residual acromegaly or Cushing's disease (CD) after resection, gamma knife radiosurgery (GKRS) is often used. Hypopituitarism is the most common adverse effect after GKRS treatment. The paucity of studies with long-term follow-up has hampered understanding of the latent risks of hypopituitarism in patients with acromegaly or CD. We report the long-term risks of hypopituitarism for patients treated with GKRS for acromegaly or CD. METHODS From a prospectively created, IRB-approved database, we identified all patients with acromegaly or CD treated with GKRS at the University of Virginia from 1989 to 2008. Only patients with a minimum endocrine follow-up of 60 months were included. The median follow-up is 159·5 months (60·1-278). Thorough radiological and endocrine assessments were performed immediately before GKRS and at regular follow-up intervals. New onset of hypopituitarism was defined as pituitary hormone deficits after GKRS requiring corresponding hormone replacement. RESULTS Sixty patients with either acromegaly or CD were included. Median tumour volume at time of GKRS was 1·3 cm(3) (0·3-13·4), and median margin dose was 25 Gy (6-30). GKRS-induced new pituitary deficiency occurred in 58·3% (n = 35) of patients. Growth hormone deficiency was most common (28·3%, n = 17). The actuarial overall rates of hypopituitarism at 3, 5 and 10 years were 10%, 21·7% and 53·3%, respectively. The median time to hypopituitarism was 61 months after GKRS (range, 12-160). Cavernous sinus invasion of the tumour was found to correlate with the occurrence of a new or progressive hypopituitarism after GKRS (P = 0·018). CONCLUSIONS Delayed hypopituitarism increases as a function of time after radiosurgery. Hormone axes appear to vary in terms of radiosensitivity. Patients with adenoma in the cavernous sinus are more prone to develop loss of pituitary function after GKRS.
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Affiliation(s)
- Or Cohen-Inbar
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Arjun Ramesh
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Mary Lee Vance
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA, USA
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Heringer LC, de Oliveira MF, Rotta JM, Botelho RV. Effect of repeated transsphenoidal surgery in recurrent or residual pituitary adenomas: A systematic review and meta-analysis. Surg Neurol Int 2016; 7:14. [PMID: 26958420 PMCID: PMC4766805 DOI: 10.4103/2152-7806.175896] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 12/21/2015] [Indexed: 12/11/2022] Open
Abstract
Background: Recurrent or residual pituitary adenomas previously treated by transsphenoidal surgery are not uncommon. There are no strongly established guidelines to perform treatment of such cases. The objective of this study is to elucidate the effect of transsphenoidal reoperation in residual or recurrent pituitary adenomas. Methods: We made a systematic review of the literature to elucidate this effect through electronic search in MEDLINE/PubMed and Cochrane Central database. PRISMA statement was used as a basis for this systematic review and analysis of the risk of bias was made according to the Grading of Recommendations, Assessment, Development and Evaluation recommendations. Results: In this review, fifteen studies were finally pooled analyzed. Although remission rates (RRs) and follow-up periods varied widely, from 149 patients with growth hormone-secreting tumors the mean RR was 44.5%, from 273 patients with adrenocorticotropic hormone-secreting tumors the mean RR was 55.5% and among 173 patients with nonsecreting tumors, RR was 76.1%. There was significant higher RR in nonsecreting tumors. Mean follow-up was 32.1 months. No difference was found between microscopic and endoscopic techniques. Conclusions: A second transsphenoidal surgery is accompanied by a chance of remission in approximately half of cases with secreting tumors. In nonsecreting ones, success is higher.
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Affiliation(s)
| | | | - José Marcus Rotta
- Department of Neurosurgery, Hospital do Servidor Público Estadual, São Paulo, Brazil
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