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Radiotherapy in acromegaly: Long-term brain parenchymal and vascular magnetic resonance changes. J Neuroradiol 2018; 45:323-328. [PMID: 29505842 DOI: 10.1016/j.neurad.2018.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 01/21/2018] [Accepted: 02/07/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Radiation therapy (RT) effectiveness on hormonal reduction is proven in acromegaly; however, collateral long-term effects are still undetermined. This transversal neuroimaging study on a large cohort of acromegalic patients aimed to investigate the rate of parenchymal and vascular changes after RT. MATERIALS AND METHODS Thirty-six acromegalic patients underwent RT (RT+) after unsuccessful surgery and were compared to RT- acromegalic patients matched for age, gender, adenoma features, clinical and surgical history. All patients underwent magnetic resonance angiography (MRA) to investigate intracranial artery abnormalities and FLAIR sequence to assess white matter changes according to the Wahlund scale. RESULTS RT+ acromegalic patients had a higher rate of controlled disease (29/36 vs. 12/36, P<0.001). RT+ acromegalic patients had MRI/MRA evaluation 15.3±9.6 years after RT. RT+ acromegalic patients had a significantly higher Wahlund score than RT- acromegalic patients (6.03±6.41 vs. 2.53±3.66, P=0.006) due to increased white matter signal abnormalities at the level of the temporal lobes, the basal ganglia (insula) and the infratentorial regions, bilaterally. Among RT+ patients one died because of temporo-polar anaplastic astrocytoma, one suffered from a stroke due to right internal carotid artery occlusion, one presented with cystic degeneration of the temporal poles. Long-dated RT (>10 years before MR evaluation) was associated with a higher rate of RT-related white matter changes (P=0.0004). CONCLUSIONS RT seems to have created a cohort of patients with brain parenchymal changes whose clinical and cognitive impact is still unknown. These patients might require a prolonged MRI and MRA follow-up to promptly detect delayed RT-related complications and minimize their clinical consequences.
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Agrawal A, Cincu R, Goel A. Current concepts and controversies in the management of non-functioning giant pituitary macroadenomas. Clin Neurol Neurosurg 2007; 109:645-50. [PMID: 17686573 DOI: 10.1016/j.clineuro.2007.06.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2007] [Revised: 06/27/2007] [Accepted: 06/30/2007] [Indexed: 10/23/2022]
Abstract
Despite their histologically benign nature, giant and 'invasive' pituitary tumors are one of the most complex neurosurgical challenges. In the present article, we discuss the current approaches to the management of giant pituitary tumors. Giant non-functioning pituitary tumors are usually confined inferiorly by the sellar dura, superiorly by the elevated diaphragma sellae, and laterally by an intact medial wall of the cavernous sinus. If the anatomical extensions of the tumor are understood and a radical tumor resection is achieved, the visual and long-term outcome can be extremely rewarding. The goals of surgery are to make a pathologic diagnosis and since the majority of these tumors are endocrinologically silent, the second goal should be to decompress the neural tissue. With the increasing experience and better understanding of anatomy of these tumors, trans-sphenoidal approaches have now replaced craniotomy for the excision of these tumors.
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Affiliation(s)
- Amit Agrawal
- Division of Neurosurgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha-442005, Maharashtra, India.
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Abstract
OBJECTIVE To evaluate efficacy and safety of radiotherapy on acromegaly treatment. DESIGN AND PATIENTS We followed retrospectively 99 acromegalic patients for at least one year after radiotherapy (RT). RT had been performed after unsuccessful surgery in 91 patients and as primary treatment in eight. Time elapsed between surgery and RT was 1.4 +/- 2.4 years. Mean follow-up after RT was 5.9 +/- 4.7 years (1-16 years). All patients were treated with linear accelerator, 89 by conventional (3240-6000 cGY) and ten by stereotactic RT. MEASUREMENTS Biochemical remission was defined as GH < 2.5 ng/ml and IGF-I normalization. RESULTS At latest follow-up, 54% of patients had serum GH level <2.5 ng/ml; 42% had normal IGF-I and 38% of patients achieved normalization of both. Controlled patients had lower baseline GH and IGF-I levels compared to uncontrolled ones. They achieved remission after 3.8 +/- 2.4 years, a significantly lower time length compared to maximum follow-up of uncontrolled (6.0 +/- 4.9 year). Results regarding GH and IGF-I levels were similar in patients treated either primarily or after surgery. No patient showed tumor growth. Visual field defects were observed in four, seizures in one, and mental disorders in two patients, although cognitive function were not properly assessed. At the last follow-up, 47% of patients had acquired at least one hormonal deficiency. CONCLUSIONS There is still a place for RT in acromegaly treatment, mainly for: after non-curative surgery and poor response or inaccessibility to medical treatment; growth restraining of aggressive macroadenomas; co-morbidities that contraindicate surgery and surgery refusal. However, side effects and latency period to achieve disease control should be kept in mind.
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Mackley HB, Reddy CA, Lee SY, Harnisch GA, Mayberg MR, Hamrahian AH, Suh JH. Intensity-modulated radiotherapy for pituitary adenomas: The preliminary report of the Cleveland Clinic experience. Int J Radiat Oncol Biol Phys 2007; 67:232-9. [PMID: 17084541 DOI: 10.1016/j.ijrobp.2006.08.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Revised: 08/08/2006] [Accepted: 08/15/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE Intensity-modulated radiotherapy (IMRT) is being increasingly used for the treatment of pituitary adenomas. However, there have been few published data on the short- and long-term outcomes of this treatment. This is the initial report of the Cleveland Clinic's experience. METHODS AND MATERIALS Between February 1998 and December 2003, 34 patients with pituitary adenomas were treated with IMRT. A retrospective chart review was conducted for data analysis. RESULTS With a median follow-up of 42.5 months, the treatment has proven to be well tolerated, with performance status remaining stable in 90% of patients. Radiographic local control was 89%, and among patients with secretory tumors, 100% had a biochemical response. Only 1 patient required salvage surgery for progressive disease, giving a clinical progression free survival of 97%. The only patient who received more than 46 Gy experienced optic neuropathy 8 months after radiation. Smaller tumor volume significantly correlated with subjective improvements in nonvisual neurologic complaints (p = 0.03), and larger tumor volume significantly correlated with subjective worsening of visual symptoms (p = 0.05). New hormonal supplementation was required for 40% of patients. Younger patients were significantly more likely to require hormonal supplementation (p = 0.03). CONCLUSIONS Intensity-modulated radiation therapy is a safe and effective treatment for pituitary adenomas over the short term. Longer follow-up is necessary to determine if IMRT confers any advantage with respect to either tumor control or toxicity over conventional radiation modalities.
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Affiliation(s)
- Heath B Mackley
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH 44195, USA.
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van den Bergh ACM, Schoorl MA, Dullaart RPF, van der Vliet AM, Szabó BG, ter Weeme CA, Pott JWR. Lack of Radiation Optic Neuropathy in 72 Patients Treated for Pituitary Adenoma. J Neuroophthalmol 2004; 24:200-5. [PMID: 15348984 DOI: 10.1097/00041327-200409000-00003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The incidence of radiation optic neuropathy (RON) after external photon beam radiation therapy for nonfunctioning pituitary adenoma (NFA) is not well-studied. Retrospective review of ophthalmological and imaging data in 72 patients with NFA treated between 1985 and 1998 with external beam radiation therapy after surgery Clinical follow-up after radiation therapy had to be at least 18 months. RON was defined as a sudden and profound irreversible visual loss affecting the optic nerve or chiasm A review of previously published cases of RON was then performed. In our cohort, no patient had RON. A total of 11 adequately documented series reports of RON were found in the medical literature on radiation-treated NFAs. The incidence of RON in NFA from these series is 0.53% (95% CI, 0.26%-0.96%). An additional 14 single RON cases have been reported, bringing the total of adequately documented RON cases to 25. RON is a rare complication after external beam radiation therapy for NFA.
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Affiliation(s)
- Alfons C M van den Bergh
- Department of Radiation Oncology, University Hospital Groningen, PPO Box 30.001, 9700 RB Groningen, The Netherlands.
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Milker-Zabel S, Zabel A, Huber P, Schlegel W, Wannenmacher M, Debus J. Stereotactic conformal radiotherapy in patients with growth hormone–secreting pituitary adenoma. Int J Radiat Oncol Biol Phys 2004; 59:1088-96. [PMID: 15234043 DOI: 10.1016/j.ijrobp.2003.12.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2003] [Revised: 11/25/2003] [Accepted: 12/10/2003] [Indexed: 12/20/2022]
Abstract
PURPOSE To evaluate the reduction of hormonal overproduction and side effects as well as survival rates after fractionated stereotactic conformal radiotherapy (FSRT) and radiosurgery in patients with growth hormone (GH)-secreting pituitary adenoma. METHODS AND MATERIALS Between January 1989 and May 2001, 25 consecutive patients were treated with FSRT (n = 20) or radiosurgery (n = 5) for GH-secreting pituitary adenoma. Nine patients were treated for recurrent disease after primary surgery. One patient had primary radiotherapy because of inoperability, and 15 patients received radiotherapy after subtotal resection due to increased GH level. Median total dose was 52.2 Gy for FSRT and 15 Gy for radiosurgery. RESULTS Radiologic local tumor control was 100% after a median follow-up of 59.8 months (range, 20.3-168.2 months). Seventeen patients had stable disease on CT/MRI, and eight showed a reduction of tumor volume on MRI scans. Endocrinologic control was 92% (23 of 25 patients). Two patients had an endocrinologic recurrence 21 and 54 months after FSRT. A normalization of preexisting acromegalic symptoms was seen in 1 patient, 4.5 years after FSRT. GH level normalized in 21 of 25 patients after 26 months median. Five of these patients underwent concurrent Octreotid therapy because of increased insulin-like growth factor I levels. Improvement of visual acuity was seen in 1 patient. New onset of clinically evident hypopituitarism as an adverse reaction of stereotactic radiotherapy was only infrequently observed in this series. CONCLUSION Stereotactic conformal radiotherapy is effective and safe in the treatment of GH-secreting pituitary adenoma to reduce hormonal overproduction and to improve local control. It is an alternative option to surgery especially for patients at high risk of surgical complications due to comorbidity.
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Affiliation(s)
- Stefanie Milker-Zabel
- Department of Clinical Radiology, Radiation Therapy, INF 400, University of Heidelberg, D-69120 Heidelberg, Germany.
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van den Bergh ACM, Dullaart RPF, Hoving MA, Links TP, ter Weeme CA, Szabó BG, Pott JWR. Radiation optic neuropathy after external beam radiation therapy for acromegaly. Radiother Oncol 2003; 68:95-100. [PMID: 12972302 DOI: 10.1016/s0167-8140(03)00202-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Alfons C M van den Bergh
- Department of Radiation Oncology, University Hospital Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
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Kopchick JJ, Parkinson C, Stevens EC, Trainer PJ. Growth hormone receptor antagonists: discovery, development, and use in patients with acromegaly. Endocr Rev 2002; 23:623-46. [PMID: 12372843 DOI: 10.1210/er.2001-0022] [Citation(s) in RCA: 210] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
An understanding of the events that occur during GH receptor (GHR) signaling has facilitated the development of a GHR antagonist (pegvisomant) for use in humans. This molecule has been designed to compete with native GH for the GHR and to prevent its proper or functional dimerization-a process that is critical for GH signal transduction and IGF-I synthesis and secretion. Clinical trials in patients with acromegaly show GHR blockade to be an exciting new mode of therapy for this condition, and pegvisomant may have a therapeutic role in diseases, such as diabetes and malignancy, in which abnormalities of the GH/IGF-I axis have been observed. This review charts the discovery and development of GHR antagonists and details the experience gained in patients with acromegaly.
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Affiliation(s)
- J J Kopchick
- Edison Biotechnology Institute, Department of Biomedical Sciences, College of Osteopathic Medicine, Ohio University, Athens, Ohio 45701, USA
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Abstract
Conventional treatments for acromegaly include surgery, radiotherapy, dopamine agonists and somatostatin (SMS) analogues, which effect disease control by lowering circulating growth hormone (GH). Due to variability in tumour characteristics, combinations of these treatment modalities leave a significant number of patients with sub-optimal serum GH and insulin-like growth factor-I (IGF-I) levels, which have been linked to increased morbidity and mortality. The GH receptor antagonist pegvisomant is a genetically engineered analogue of GH that prevents functional dimerisation of the growth hormone receptor (GHR); a process that is critical to GH action at the cellular level. A crucial amino acid substitution at Gly(120) to Arg(120) within the third alpha helix of the antagonist prevents functional GHR dimerisation. Pegvisomant represents a novel treatment for acromegaly as, unlike existing treatment modalities, the effectiveness of pegvisomant is independent of pituitary tumour characteristics. Initial clinical studies in patients with active acromegaly have demonstrated serum IGF-I normalisation in over 90% of patients receiving 20 mg per day, such that, in terms of serum IGF-I normalisation, pegvisomant now represents the most effective medical treatment for acromegaly. Although there are limited long-term data on the use of pegvisomant and questions regarding pituitary tumour growth and altered liver function remain, this therapy offers the prospect of serum IGF-I normalisation in the vast majority of patients with active acromegaly.
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Affiliation(s)
- C Parkinson
- Department of Endocrinology, Christie Hospital, Wilmslow Road, Manchester, M20 4BX, UK
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Ikeda H, Jokura H, Yoshimoto T. Transsphenoidal surgery and adjuvant gamma knife treatment for growth hormone-secreting pituitary adenoma. J Neurosurg 2001; 95:285-91. [PMID: 11780899 DOI: 10.3171/jns.2001.95.2.0285] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The results of combined transsphenoidal surgery and adjuvant gamma knife surgery (GKS) for growth hormone (GH)-secreting adenoma were investigated using biochemical cure criteria for surgery and biological cure criteria for adjuvant GKS. METHODS Ninety patients (42 male and 48 female patients), ranging from 11 to 75 years of age, underwent transsphenoidal surgery for GH-secreting pituitary adenoma. Preoperative and postoperative GH and insulin-like growth factor-I levels were measured, as was the postoperative GH level after the oral glucose tolerance test. Tumor size, cavernous sinus (CS) invasion, and residual tumor were evaluated using magnetic resonance (MR) imaging. Transsphenoidal microsurgery was performed, followed by adjuvant GKS when there was persistent biochemical evidence of GH hypersecretion with residual tumor detectable in the CS on MR imaging. Patients in whom GKS was contraindicated were treated with conventional radiotherapy or by medical means. CONCLUSIONS The overall surgical cure rate was 57% based on recently accepted biochemical cure criteria. Patients with no CS invasion achieved a 100% cure rate, whereas patients with CS invasion achieved an 82% cure rate (14 of 17 patients) after adjuvant GKS. The combination of transsphenoidal microsurgery and adjuvant GKS is the optimal therapy for patients with GH-secreting adenoma.
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Affiliation(s)
- H Ikeda
- Department of Neurosurgery, Tohoku University School of Medicine, Sendai, Japan.
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Milker-Zabel S, Debus J, Thilmann C, Schlegel W, Wannenmacher M. Fractionated stereotactically guided radiotherapy and radiosurgery in the treatment of functional and nonfunctional adenomas of the pituitary gland. Int J Radiat Oncol Biol Phys 2001; 50:1279-86. [PMID: 11483339 DOI: 10.1016/s0360-3016(01)01535-8] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE We evaluated survival rates and side effects after fractionated stereotactically guided radiotherapy (SCRT) and radiosurgery in patients with pituitary adenoma. METHODS AND MATERIALS Between 1989 and 1998, 68 patients were treated with FSRT (n = 63) or radiosurgery (n = 5) for pituitary adenomas. Twenty-six had functional and 42 had nonfunctional adenomas. Follow-up included CT/MRI, endocrinologic, and ophthalmologic examinations. Mean follow-up was 38.7 months. Seven patients received radiotherapy as primary treatment and 39 patients received it postoperatively for residual disease. Twenty-two patients were treated for recurrent disease after surgery. Mean total dose was 52.2 Gy for SCRT, and 15 Gy for radiosurgery. RESULTS Overall local tumor control was 93% (60/65 patients). Forty-three patients had stable disease based on CT/MRI, while 15 had a reduction of tumor volume. After FSRT, 26% with a functional adenoma had a complete remission and 19% had a reduction of hormonal overproduction after 34 months' mean. Two patients with STH-secreting adenomas had an endocrinologic recurrence, one with an ACTH-secreting adenoma radiologic recurrence, within 54 months. Reduction of visual acuity was seen in 4 patients and partial hypopituitarism in 3 patients. None of the patients developed brain radionecrosis or radiation-induced gliomas. CONCLUSION Stereotactically guided radiotherapy is effective and safe in the treatment of pituitary adenomas to improve local control and reduce hormonal overproduction.
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Affiliation(s)
- S Milker-Zabel
- Department of Clinical Radiology, Radiation Therapy, University of Heidelberg, Heidelberg, Germany.
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Biermasz NR, Dulken HV, Roelfsema F. Postoperative radiotherapy in acromegaly is effective in reducing GH concentration to safe levels. Clin Endocrinol (Oxf) 2000; 53:321-7. [PMID: 10971449 DOI: 10.1046/j.1365-2265.2000.01095.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Several studies have established that in treated acromegaly mortality is only normalized in patients achieving a serum GH concentration below 5 mU/l. Few studies however, have addressed results of radiotherapy using this strict criterion. The aim of our study was to assess the efficacy of postoperative radiotherapy in reducing serum GH concentration below 5 mU/l. PATIENTS AND METHODS Forty acromegalic patients who underwent radiotherapy for postoperative persistent disease after transsphenoidal surgery were studied. Mean time of follow-up after radiotherapy was 123+/-11.1 months. A serum GH concentration of <5 mU/l was used to define remission. RESULTS Following surgery mean GH concentration decreased from 120.8+/-21 mU/l to 24.4+/-5.2 mU/l and mean GH concentration prior to radiotherapy, administered after a mean of 8.2+/-2.7 (0.5-96) months postoperatively was 26.0+/-5.1 mU/l. Using individual regression plots, GH was reduced to 50% by radiotherapy after a mean of 27+/-5 months (range 3-105 months). The observed mean GH concentration as measured at follow-up visits was reduced by 55% (-36-95%) after the first year, by 65% (-29-97.3%) after 2 years and by 78% (-29-99%) after 5 years. We could not demonstrate a significant correlation between a normalized GH concentration on the one hand and tumour size, preradiotherapy GH concentration or duration of follow-up on the other hand. During follow-up, GH-suppressive medical therapy was used in 11 patients, five of whom were still using medication at the end of follow-up. Eight patients had a follow-up of less than 5 years and three of them had a serum GH concentration of <5 mU/l at their latest follow-up visit (38%). At 5 years of follow-up after radiotherapy, 24 out of 32 patients had a GH level of <5 mU/l without medication (75%). At 10 years following irradiation, 16 of 21 patients (76%) had a GH level of <5 mU/l without medical treatment. At 15 years follow-up, a serum GH concentration of <5 mU/l was observed in 13 out of 15 patients (87%) without GH suppressive medication. At the latest follow-up visit, serum GH concentration below 5 mU/l was present in 75% of patients (30 out of 40) without medical therapy after a mean of 10.4+/-0.9 years, but five patients required octreotide up to the end of follow-up. Twenty-seven out of 37 patients with available IGF-I data had normal IGF-I at the end of follow-up (73%). Fifty percent of patients needed substitution therapy for (partial) hypopituitarism after 10 years and 75% after 15 years of radiotherapy. CONCLUSION In our group of patients who were incompletely cured by surgery, but had a significant postoperative decrease of serum GH concentrations, radiotherapy was able to achieve 'safe' serum GH concentrations in the majority in the long term.
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Affiliation(s)
- N R Biermasz
- Departments of Endocrinology & Metabolism, Leiden University Medical Centre, Leiden, The Netherlands
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Rivoal O, Brézin AP, Feldman-Billard S, Luton JP. Goldmann perimetry in acromegaly: a survey of 307 cases from 1951 through 1996. Ophthalmology 2000; 107:991-7. [PMID: 10811095 DOI: 10.1016/s0161-6420(00)00060-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Because visual pathway lesions are a common complication of pituitary tumors, visual field examinations in patients with acromegaly were studied. Proportion and outcome of visual field defects in patients with acromegaly were evaluated. DESIGN Large, retrospective case series. PARTICIPANTS We reviewed 307 cases of acromegaly seen from 1951 through 1996 at a single referral center. METHODS Kinetic visual field testing had been performed with the Goldmann perimeter, and the frequency of visual field defects and their correlation with other clinical manifestations and characteristics of the adenoma were examined. MAIN OUTCOME MEASURES Repeat visual field examinations. RESULTS Of the 307 patients included in the analysis, a visual field defect that could be attributed to the pituitary adenoma was observed in 62 (20.2%) during follow-up. Visual field defects were bilateral in 38 (61.3%) of these cases. Patients with visual field abnormalities were significantly younger (P = 0.04), had larger tumors (P < 0.001), had more suprasellar extensions (P < 0.001), and had higher levels of growth hormone in their serum (P = 0.04) than patients free of visual field defects. At the end of the follow-up period, visual field examination remained abnormal in 32 (10.4%). Return to a normal visual field examination after treatment was more frequently observed in patients who were less than 40 years of age at the time of diagnosis (P = 0.004). Secondary empty sella syndrome was the main cause of visual field defects after treatment. Abnormal visual field, either at the time of diagnosis or during follow-up, decreased from 27% of patients between 1951 and 1975 to 15.4% of patients between 1976 and 1996, when modern neuroimaging techniques became available. CONCLUSIONS Endocrinologic and neuroimaging follow-up of patients with acromegaly should be accompanied by ophthalmic assessment. Factors predictive of visual field defects have been identified.
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Affiliation(s)
- O Rivoal
- Service d'ophtalmoloige, Hôpital Cochin, Paris, France.
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Powell JS, Wardlaw SL, Post KD, Freda PU. Outcome of radiotherapy for acromegaly using normalization of insulin-like growth factor I to define cure. J Clin Endocrinol Metab 2000; 85:2068-71. [PMID: 10843197 DOI: 10.1210/jcem.85.5.6586] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Radiation therapy (RT) has traditionally been considered a useful additional therapy for patients with acromegaly not achieving biochemical remission after surgery. However, recent evidence has suggested that RT is not curative in most patients with acromegaly when normalization of the serum insulin-like growth factor I (IGF-I) level is used to define remission. Therefore, we evaluated the success of RT based on IGF-I level in the 47 patients who received RT as part of their treatment from the cohort of 161 patients with acromegaly seen by us between 1981 and 1999. Four patients in whom no post-RT IGF-I level was available were excluded from the analysis. Of the remaining 43 patients, 32 patients received external beam RT, 6 received fractionated stereotactic radiosurgery, 4 received gamma-knife RT, and 1 received proton beam RT. The most recent IGF-I levels in these 43 patients, obtained a mean of 5.2 yr post-RT (range, 0.8-13.2 yr), were compared to age-adjusted normal ranges. IGF-I levels were normal in 17 patients (39.5%) without the addition of medical therapy. The percentage of patients with a normal IGF-I level generally increased with time post-RT; 27% of patients less than 6 yr post-RT, but 69.2% of patients 6 yr or more post-RT had normal IGF-I levels. Using the more traditional criterion for cure, a random GH measurement, 74% of patients had a GH level below 5 ng/mL, and 44% had a GH level below 2.5 ng/mL and would have been considered in remission based on these criteria. We conclude that with time RT remains a useful adjunctive treatment for many patients with acromegaly. RT should be considered along with appropriate medical therapy in selected patients who do not achieve normalization of IGF-I level after surgery or for those resistant to medical therapy.
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Affiliation(s)
- J S Powell
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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Oruçkaptan HH, Senmevsim O, Ozcan OE, Ozgen T. Pituitary adenomas: results of 684 surgically treated patients and review of the literature. SURGICAL NEUROLOGY 2000; 53:211-9. [PMID: 10773251 DOI: 10.1016/s0090-3019(00)00171-3] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The outcome of patients with pituitary adenomas who were treated surgically with or without postoperative radiotherapy was analyzed. The purpose of this study was to determine the factors that strongly influence (A) tumor control, (B) the efficacy of surgery, and (C) radiotherapy based on the hormonal activity of adenomas and its invasion characteristics. METHODS Between 1982-1996, 684 patients with the diagnosis of pituitary adenoma were operated on. The mean age was 38 years and the mean follow-up time was 40.5 months. A total of 516 patients who were followed for more than 1 year were studied to analyze the effect of treatment modalities and invasion characteristics on tumor control. There were 297 patients with prolactinomas, 118 patients with somatotropinomas, 45 with corticotropinomas, 17 with mixed adenomas, two with thyrotropinomas, and 205 with null cell adenomas. All patients were classified according to Hardy's modified radiological classification scheme and analyzed in invasive and noninvasive groups individually based on this classification system. In the early postoperative period, 230 of these patients were given conventional radiotherapy with a mean dose of 4400 cGy. The following factors were analyzed for prognostic significance in tumor control: the effects of surgery and radiotherapy based on tumor types and invasion characteristics, the existence of histologically proven invasion of the dura mater overlying the sellar floor, and the early results of topical bromocriptine application in macroprolactinoma patients. RESULTS Overall surgical complications and mortality rate were similar to those of large series reported in the literature. Except for the invasive somatotropinomas and null cell adenomas, statistical analysis demonstrated the ineffectiveness of radiotherapy on tumor control. We did not detect any positive correlation between the recurrence rate and mean recurrence time or dural invasion of the sellar floor. Topical bromocriptine application seemed to improve tumor control in 21 selected macroprolactinoma patients. CONCLUSION Conventional radiotherapy is not as effective as expected, considering its adverse effects. The increased side effects of radiotherapy in cases with supra-parasellar extension, especially to the optic pathway and hypothalamus, limit its benefits, which could be demonstrated only in invasive somatotropinomas and null cell adenomas. In contrast with our current beliefs, tumoral infiltration of the sellar dura mater is not a prognostic factor for recurrence and therefore should not be a criterion for radiotherapy after surgery. Topical application of bromocriptine into the sellar cavity after tumor removal seems to provide superior results compared with the conventional treatment modalities.
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Affiliation(s)
- H H Oruçkaptan
- Department of Neurosurgery, Hacettepe University School of Medicine, Ankara, Turkey
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Abstract
Stereotactic radiosurgery with the Gamma Knife allows the delivery of focused radiation in a single session from a Cobalt-60 source to a pituitary tumor with little radiation to surrounding normal brain tissue. At this time the major role for Gamma Knife radiosurgery in acromegaly is for the treatment of failed pituitary surgery although it may also by used as primary treatment for patients unwilling or unsuitable, for medical reasons, to undergo transsphenoidal surgery. The major risk from Gamma Knife radiosurgery appears to be radiation damage to the visual pathways, but this can be obviated by limiting the radiation dose to the optic chiasm under 10 Gy. In contrast, the neuronal and vascular structures running in the cavernous sinus are much less radiosensitive allowing an ablative dose to be administered to tumors showing lateral invasion and impinging on cranial nerves III, IV, V and VI. Gamma Knife radiosurgery appears to produce effects in GH secreting tumors faster than with fractionated radiotherapy without the potential long-term risk of developing a second extrapituitary brain tumor as well as the neuropsychiatric effects associated with conventional radiation administration.
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Affiliation(s)
- I M Jackson
- Department of Medicine, Rhode Island Hospital, Providence 02903, USA.
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Abstract
The most common indication for the use of radiation therapy in the treatment of benign central nervous system disease is for the treatment of benign brain tumors, such as meningioma, pituitary adenoma, acoustic neuroma, arteriovenous malformation, and craniopharyngioma. Other less common benign intracranial tumors treated with radiation include chordoma, pilocytic astrocytoma, pineocytoma, choroid-plexus papilloma, hemangioblastoma, and temporal bone chemodectomas. Benign conditions, such as histiocytosis X, trigeminal neuralgia, and epilepsy, are also amenable to radiation treatment. There have also been reports of radiosurgery being used for the treatment of movement disorders and psychiatric disturbances, such as obsessive-compulsive and anxiety disorders. For benign brain tumors, radiation therapy as either primary or adjuvant therapy plays an integral role in improving local control. In the treatment of trigeminal neuralgia, epilepsy, tremor, and some psychiatric disturbances, radiosurgery may help ameliorate or eliminate some symptoms. Patients with benign central nervous system disease are expected to live a long time. As such, treatment should be highly conformal and based on three-dimensional planning using magnetic resonance imaging, computed tomography, or both. It is critical that damage to normal brain be minimized.
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Affiliation(s)
- M N Tsao
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California 94143, USA
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Landolt AM, Haller D, Lomax N, Scheib S, Schubiger O, Siegfried J, Wellis G. Stereotactic radiosurgery for recurrent surgically treated acromegaly: comparison with fractionated radiotherapy. J Neurosurg 1998; 88:1002-8. [PMID: 9609294 DOI: 10.3171/jns.1998.88.6.1002] [Citation(s) in RCA: 167] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECT The authors tested the assumption that gamma knife radiosurgery is more effective than fractionated radiotherapy for the treatment of patients with acromegaly who have undergone unsuccessful resective surgery. Untreated and uncured acromegaly causes illness and death. Acromegalic patients in whom growth hormone and, particularly, insulin-like growth factor I are not normalized must undergo further treatment. METHODS After unsuccessful operations, 16 patients suffering from recurrent and uncured acromegaly underwent stereotactic radiosurgery (25 Gy to the tumor margin, 50 Gy maximum), the outcome of which was compared with the result obtained in 50 patients who received fractionated radiotherapy (40 Gy). The cumulative distribution functions of the two groups (Kaplan-Meier estimate) differed significantly (p < 0.0001 in the log-rank test of Mantel). The mean time to simultaneous normalization of both parameters was 1.4 years in the group treated with the gamma knife and 7.1 years in the group treated with fractionated radiotherapy. CONCLUSIONS The authors suggest the use of stereotactic radiosurgery as the preferred treatment for recurrent acromegaly resulting from unsuccessfully resected tumors.
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Affiliation(s)
- A M Landolt
- Neurosurgery Department, Institute of Neuroradiology, Klinik Im Park, Zürich, Switzerland.
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Colin P, Scavarda D, Delemer B, Nakib I, Caron J, Bazin A, Bernard MH, Peruzzi P, Scherpereel B, Fauchon V, Delannes M, Redon C, Rousseaux P. [Fractionated stereotactic radiotherapy: results in hypophyseal adenomas, acoustic neurinomas, and meningiomas of the cavernous sinus]. Cancer Radiother 1998; 2:207-14. [PMID: 9749116 DOI: 10.1016/s1278-3218(98)89092-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE In order to optimize cerebral benign tumor irradiation, fractionated stereotactic radiotherapy allows a focused-volume irradiation (2.1 cm3, 16 mm diameter) under standard fractionation conditions. Results of a retrospective and multicentric analysis are presented. PATIENTS AND METHODS Fractionated stereotactic radiotherapy uses the ballistic principles of the radiosurgery: stereotactic localization, multi-beam irradiation, secondary collimation, three-dimensional dosimetry. Standard fractionation is possible with a re-locatable non-invasive stereotactic device. The technique has been used for treating pituitary adenomas (86 patients), acoustic neuromas (32 patients) and cavernous meningiomas (26 patients). RESULTS 1) pituitary adenomas: cumulative tumoral objective-response rates (42 patients) were respectively 42%, 69% and 88% at 24, 48 and 60 months. The cumulative endocrinologic objective-response rates (32 patients) were respectively 53%, 75% and 85% at 24, 48 and 60 months. The cumulative risk of radio-induced hormonal deficiency varied from 18% (growth hormone [GH]) to 42% for TSH (thyroid stimulating hormone) at 48 months. No other complication was observed; 2) acoustic neuromas: 33 tumors, < 25 mm in diameter, were treated in 32 patients. Tumor control was observed in 29/33 tumors: 14 were stable, 15 decreased and three progressed. Useful hearing was maintained in 9/10 patients. Only three patients (9%) presented persistent complications; 3) cavernous meningioma: 17/19 clinical responses were noted, 20 tumoral stabilisations, one partial response and one progression (22 magnetic resonance imaging [MRI] evaluable patients). One unilateral radio-induced blindness was observed. CONCLUSION For these benign tumors, the focused target volume obtained by the fractionated stereotactic radiotherapy seems to be better adapted to the treatment of limited benign tumors than standard radiotherapy. The use of standard fractionation reduces the risk of severe normal tissue damage, sometimes observed for radiosurgery and inherent in the use of single fraction.
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Affiliation(s)
- P Colin
- Service d'oncologie médicale et de radiothérapie, polyclinique Courlancy, Reims, France
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Leber KA, Berglöff J, Pendl G. Dose-response tolerance of the visual pathways and cranial nerves of the cavernous sinus to stereotactic radiosurgery. J Neurosurg 1998; 88:43-50. [PMID: 9420071 DOI: 10.3171/jns.1998.88.1.0043] [Citation(s) in RCA: 324] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED As the number of patients treated with stereotactic radiosurgery increases, it becomes particularly important to define with precision adverse effects on distinct structures of the nervous system. OBJECT This study was designed to assess the dose-response tolerance of the visual pathways and cranial nerves after exposure of the cavernous sinus to radiation. METHODS A total of 66 sites in the visual system and 210 cranial nerves of the middle cranial fossa were investigated in 50 patients who had undergone gamma knife treatment for benign skull base tumors. The mean follow-up period was 40 months (range 24-60 months). Follow-up examinations consisted of neurological, neuroradiological, and neuroophthalmological evaluations. The actuarial incidence of optic neuropathy was zero for patients who received a radiation dose of less than 10 Gy, 26.7% for patients receiving a dose in the range of 10 to less than 15 Gy, and 77.8% for those who received doses of 15 Gy or more (p < 0.0001). Previously impaired vision improved in 25.8% and was unchanged in 51.5% of patients. No sign of neuropathy was seen in patients whose cranial nerves of the cavernous sinus received radiation doses of between 5 and 30 Gy. Because tumor control appeared to have been achieved in 98% of the patients, the deterioration in visual function cannot be attributed to tumor progression. CONCLUSIONS The structures of the visual pathways (the optic nerve, chiasm, and tract) exhibit a much higher sensitivity to single-fraction radiation than other cranial nerves, and their particular dose-response characteristics can be defined. In contrast, the oculomotor and trigeminal nerves have a much higher dose tolerance.
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Affiliation(s)
- K A Leber
- Department of Neurosurgery, Karl Franzens University, School of Medicine, Graz, Austria.
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van Lindert E, Hey O, Boecher-Schwarz H, Perneczky A. Treatment results of acromegaly as analyzed by different criteria. Acta Neurochir (Wien) 1997; 139:905-12; discussion 912-3. [PMID: 9401649 DOI: 10.1007/bf01411298] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Results of treatment of acromegaly are often incomparable due to the different criteria which have been used for defining cure or control of disease. At the present time it is widely accepted, that the main criteria of cure must be normalization of IGF-1 and a GH in the OGTT < 2 ng/ml. In this retrospective study we investigated the endocrinological results of 56 patients, who were surgically treated because of a GH-producing pituitary adenoma, by different criteria. Twelve of our patients had had additional medical treatment after surgery, two received radiotherapy. At a mean follow-up of 34 months after surgery 66% of patients had a basal GH < 5 ng/ml, 64% had a GH in the OGTT < 2 ng/ml and 73% had normalization of IGF-1. The combined criteria of OGTT < 2 ng/ml and IGF-1 normalization have been fulfilled in 59% of patients. None of these latter patients developed a clinical recurrence during the follow-up period. An optimal result (endocrinological cure, no permanent surgical complications and intact pituitary function) was achieved in 43% of patients. Although surgery was responsible for 19 new pituitary axis deficiencies (7 corticotropic axis, 8 thyrotropic axis and gonadotropic axis), 22 partial deficiencies improved to normalization after surgery (respectively 6, 3, and 13). Pre-operatively 55% of patients had no pituitary deficiency, after surgery this was 61%, leaving a net positive result of 6% less pituitary deficiencies. The authors conclude that normalization of IGF-1 combined with an OGTT < 2 ng/ml are adequate criteria for the definition of cure of acromegaly. However, the authors propose to include post-treatment hypopituitarism as an additional criterion by which treatment of acromegaly should be evaluated.
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Affiliation(s)
- E van Lindert
- Department of Neurosurgery, Johannes Gutenberg University, Mainz, Federal Republic of Germany
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Affiliation(s)
- I Shimon
- Division of Endocrinology and Metabolism, Cedars-Sinai Medical Center, Los Angeles, CA 90048-1865, USA
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Tsang RW, Brierley JD, Panzarella T, Gospodarowicz MK, Sutcliffe SB, Simpson WJ. Role of radiation therapy in clinical hormonally-active pituitary adenomas. Radiother Oncol 1996; 41:45-53. [PMID: 8961367 DOI: 10.1016/s0167-8140(96)91807-1] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE The outcome following radiation therapy (RT) of hormonally-active pituitary adenomas was assessed. The purpose of this analysis was to determine the control rate after radiation, identify any prognostic factors and evaluate the late toxicity. MATERIALS AND METHODS From 1972 to 1986, 145 patients received RT for hormonally-active pituitary adenomas. The median age was 39 years (range 15-76), with 81 males and 64 females. There were 52 patients with acromegaly, 64 with prolactinoma, and 29 with Cushing's disease. The median follow-up was 7.3 years. RT was given as primary treatment in 17 patients, after initial surgery in 65 patients, and as part of salvage therapy in 63 patients. The median total dose was 50 Gy (daily fraction: 2 Gy). Tumor control was defined as normalization of basal hormonal level and lack of progression of adenoma assessed by imaging studies. The following factors were analyzed for prognostic significance in tumor control: age, sex, tumor type, direction of tumor extension, radiation dose, and radiation field size. RESULTS The 10-year actuarial proportion of patients with persistent elevated hormone level were 61% following RT alone, and 44% with the addition of medical management. The progression-free rate was 96% at 10 years. Of the 20 deaths, three patients died with uncontrolled pituitary adenoma and three died of treatment complications. The actuarial 10-year overall and cause-specific survival rates were 86% and 97%. The actuarial rates of radiation-induced hypopituitarism were 35%, 22% and 22% at 10 years for thyroid, glucocorticoid and gonadal functions, respectively. None of the factors examined were found to be significant predictors of tumor control. CONCLUSIONS Post-operative external beam RT is highly effective in preventing recurrence of space-occupying effects of hormonally-active pituitary adenomas. However, long-term biochemical remission is observed only in approximately 40% of patients (at 10 years), with an additional 20% requiring medical therapy. Malignancies of the CNS can develop as an infrequent late event.
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Affiliation(s)
- R W Tsang
- Department of Radiation Oncology, University of Toronto, Princess Margaret Hospital/Ontario Cancer Institute, Canada
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Goldsmith BJ, Shrieve DC, Loeffler JS. High efficacy without visual damage: the current status of pituitary radiotherapy. Int J Radiat Oncol Biol Phys 1995; 33:765-7. [PMID: 7558970 DOI: 10.1016/0360-3016(95)02127-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Zierhut D, Flentje M, Adolph J, Erdmann J, Raue F, Wannenmacher M. External radiotherapy of pituitary adenomas. Int J Radiat Oncol Biol Phys 1995; 33:307-14. [PMID: 7673017 DOI: 10.1016/0360-3016(95)00071-6] [Citation(s) in RCA: 124] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To evaluate therapeutic outcome and side effects of radiotherapy in pituitary adenomas as sole or combined treatment. METHODS AND MATERIALS Retrospective analysis of 138 patients (74 male, 64 female) irradiated for pituitary adenoma from 1972 to 1991 was performed. Mean age was 49.7 years (15-80 years). Regular follow-up (in the mean 6.53 +/- 3.99 years) included radiodiagnostical [computed tomography (CT), magnetic resonance imaging (MRI), x-ray], endocrinological, and ophthalmological examinations. Seventy patients suffered from nonfunctional pituitary adenoma, 50 patients suffered from growth-hormone producing adenomas, 11 had prolactinomas, and 7 patients had adrenocorticotropic hormone (ACTH) producing pituitary adenomas. In 99 patients surgery was followed by radiotherapy in case of suspected remaining tumor (invasive growth of the adenoma, assessment of the surgeon, pathologic CT after surgery, persisting hormonal overproduction). Twenty-three patients were treated for recurrence of disease after surgery and 16 patients received radiation as primary treatment. Total doses from 40-60 Gy (mean: 45.5 Gy) were given with single doses of 2 Gy 4 to five times a week. RESULTS Tumor control was achieved in 131 patients (94.9%). In seven patients, recurrence of disease was diagnosed in the mean 2.9 years (9-98 months) after radiotherapy and salvaged by surgery. A statistically significant dose-response relationship was found in favor of doses > or = 45 Gy. Ninety percent of the patients with hormonally active pituitary adenomas had a benefit from radiotherapy in means of complete termination (38%) or at least reduction (52%) of hormonal overproduction. Partial or complete hypopituitarism after radiotherapy developed, depending on hormonal axis, in 12 (prolactin) to 27% (follicle-stimulating hormone FSH) of patients who had not already had hypopituitarism prior to radiation. Two out of 138 patients suffered reduction of visual acuity, which was, in part, related to radiotherapy. Both therapeutic effects and side effects occurred after a latency period of 3 months up to 9 years. CONCLUSION We conclude that radiotherapy of pituitary adenomas, using modern treatment planning techniques, is effective and safe. To achieve optimal tumor control, doses of 45-48 Gy (conventionally fractionated) should be applied.
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Affiliation(s)
- D Zierhut
- Department of Clinical Radiology, University of Heidelberg, Germany
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Jamjoom ZA, Al-Maatouq M, Jamjoom AH, Malabarey T, Al-Rubeaan K, Ur-Rahman N, Baharoon S. Growth hormone secreting pituitary adenoma: Clinical aspects and surgical outcome. Ann Saudi Med 1995; 15:178-82. [PMID: 17587934 DOI: 10.5144/0256-4947.1995.178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Z A Jamjoom
- Departments of Neurosurgery, Endocrinology and Radiology, College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia
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Bliss P, Kerr GR, Gregor A. Incidence of second brain tumours after pituitary irradiation in Edinburgh 1962-1990. Clin Oncol (R Coll Radiol) 1994; 6:361-3. [PMID: 7873481 DOI: 10.1016/s0936-6555(05)80187-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Two hundred and ninety-six patients irradiated for pituitary adenoma in Edinburgh between 1962 and 1990 were reviewed. The number of subsequent tumours was noted. The expected incidence of tumours was estimated, based on data from the Scottish Cancer Registry, for an age and sex matched population. One malignant brain tumour was found; the expected incidence was 0.3 (95% CI 0-12). One meningioma was reported. Thirty non-CNS tumours were found, compared with an expected incidence of 17.5 (95% CI 12-26). We see no reason at present to alter our practice as a result of radiation induced neoplasia in this group, although close follow-up continues.
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Affiliation(s)
- P Bliss
- Western General Hospital, Edinburgh, UK
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Tsang RW, Laperriere NJ, Simpson WJ, Brierley J, Panzarella T, Smyth HS. Glioma arising after radiation therapy for pituitary adenoma. A report of four patients and estimation of risk. Cancer 1993; 72:2227-33. [PMID: 8374881 DOI: 10.1002/1097-0142(19931001)72:7<2227::aid-cncr2820720727>3.0.co;2-i] [Citation(s) in RCA: 192] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Many case reports in the literature associate cranial radiation therapy with the development of brain tumors. Quantitation of the risk of second brain tumors after irradiation in childhood is available, but it is seldom reported for those treated by radiation therapy as adults. METHODS A retrospective review was made of 367 patient records registered at the Princess Margaret Hospital with a diagnosis of pituitary adenoma from 1972 to 1986. Three hundred five patients treated with megavoltage radiation therapy form the basis of this report. Second brain tumors were identified and the patient case histories described. The risk of second brain tumor after irradiation was estimated by calculating the observed/expected (O/E) ratio, age- and sex-adjusted to the Ontario population. RESULTS Of the 305 patients in this study, 4 had glioma of the brain. All gliomas arose within the previous radiation field(s), with a latency of 8-15 years after radiation therapy. Additional treatment was compromised by the location of the glioma and the moderately high doses of radiation received previously; all four patients died of their gliomas. Our cohort of patients had a relative risk of malignant brain tumor 16 times greater than that of the general population in Ontario (P < 0.001; 95% confidence interval, 4.4-41). The cumulative actuarial risk of secondary glioma after radiation therapy was 1.7% at 10 years and 2.7% at 15 years. CONCLUSIONS There was a clinically significant increased risk of malignant brain tumor developing after radiation therapy for pituitary adenoma. Because there is no reported association between pituitary adenomas and gliomas of brain, this excess risk is attributed to irradiation. Before advising radiation therapy for pituitary adenoma, the risk:benefit ratio, including the risk of secondary brain tumors, should be carefully considered.
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Affiliation(s)
- R W Tsang
- Department of Radiation Oncology, Princess Margaret Hospital, Toronto, Ontario, Canada
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Brada M, Ford D, Ashley S, Bliss JM, Crowley S, Mason M, Rajan B, Traish D. Risk of second brain tumour after conservative surgery and radiotherapy for pituitary adenoma. BMJ (CLINICAL RESEARCH ED.) 1992; 304:1343-6. [PMID: 1611331 PMCID: PMC1882057 DOI: 10.1136/bmj.304.6838.1343] [Citation(s) in RCA: 330] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the risk of second brain tumour in patients with pituitary adenoma treated with conservative surgery and external beam radiotherapy. DESIGN Long term follow up of a cohort of patients with pituitary adenoma and comparison of tumour occurrence with population incidence rates. SETTING The Royal Marsden Hospital. SUBJECTS 334 patients with pituitary adenoma treated with conservative surgery and radiotherapy (median dose 45 Gy) and followed up for 3760 person years. MAIN OUTCOME MEASURES Second intracranial tumour and systemic malignancy. RESULTS Five patients developed a second brain tumour: two had astrocytoma, two meningioma, and one meningeal sarcoma. The cumulative risk of developing a second brain tumour over the first 10 years after treatment was 1.3% (95% confidence interval 0.4% to 3.9%) and over 20 years 1.9% (0.7% to 5.0%). The relative risk of a second brain tumour compared with the incidence in the normal population was 9.38 (3.05 to 21.89). There was no excess risk of any other type of second primary malignancy. CONCLUSIONS There is an increased risk of second intracranial tumour in patients with pituitary adenoma treated with surgery and radiotherapy. Although radiation is likely to be the most important factor contributing to the excess risk, further study is required in a cohort of similar patients not receiving radiation.
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Affiliation(s)
- M Brada
- Institute of Cancer Research, Sutton, Surrey
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