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González-Virla B, Vargas-Ortega G, Romero-Gameros CA. Radiotherapy and Mortality in Pituitary Adenomas. Arch Med Res 2023; 54:102900. [PMID: 37940504 DOI: 10.1016/j.arcmed.2023.102900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 09/13/2023] [Accepted: 10/19/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Pituitary adenomas (PA), comprising 10-20% of intracranial tumors, are classified as functioning and non-functioning and are further divided by size. Non-functioning tumors cause mechanical symptoms while functioning ones result in hormonal hypersecretion syndromes. Initial treatment involves surgery, with medical treatment for prolactinomas. Radiotherapy (RT) is employed as an adjuvant treatment, with various modalities including conventional, stereotactic radiosurgery (SRS), and fractionated stereotactic RT (FSRT). Although effective, RT is associated with complications and toxicities such as hypopituitarism, optic neuritis, secondary CNS tumors, and neurocognitive deficits. AIM Describe the information on mortality from radiotherapy as treatment of functioning PA. METHODS A PubMed search spanning 2000-2017 was conducted for articles on pituitary RT. RESULTS Conventional RT entails high-energy radiation over multiple sessions, while SRS delivers precise high doses in a single session. FSRT offers enhanced precision using a linear accelerator, delivering multiple doses. Optic structure proximity and tumor volume dictate RT modality. Studies have shown SRS and FSRT's efficacy in tumor and endocrine control, with variable risks and complications. Mortality rates in pituitary adenomas treated with RT have been evaluated, revealing complexities. Acromegaly, associated with increased mortality due to cerebrovascular disease, may result from RT. Irradiation of non-functioning pituitary macroadenomas also elevates cerebrovascular risk, while radiotherapy-induced hypopituitarism is associated with increased cardiovascular mortality. RT-induced damage is attributed to microvascular lesions and arteriolar changes. CONCLUSION Modern techniques mitigate complications, and although safer, long-term studies are needed. Multidisciplinary evaluation guides the treatment decision, optimizing efficacy and minimizing risk, ultimately improving the patient's quality of life.
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Affiliation(s)
- Baldomero González-Virla
- Endocrinology Service, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
| | - Guadalupe Vargas-Ortega
- Endocrinology Service, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Carlos Alfonso Romero-Gameros
- Otorrinolaringology Service, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Iannalfi A, Riva G, Ciccone L, Orlandi E. The role of particle radiotherapy in the treatment of skull base tumors. Front Oncol 2023; 13:1161752. [PMID: 37350949 PMCID: PMC10283010 DOI: 10.3389/fonc.2023.1161752] [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: 02/08/2023] [Accepted: 05/19/2023] [Indexed: 06/24/2023] Open
Abstract
The skull base is an anatomically and functionally critical area surrounded by vital structures such as the brainstem, the spinal cord, blood vessels, and cranial nerves. Due to this complexity, management of skull base tumors requires a multidisciplinary approach involving a team of specialists such as neurosurgeons, otorhinolaryngologists, radiation oncologists, endocrinologists, and medical oncologists. In the case of pediatric patients, cancer management should be performed by a team of pediatric-trained specialists. Radiation therapy may be used alone or in combination with surgery to treat skull base tumors. There are two main types of radiation therapy: photon therapy and particle therapy. Particle radiotherapy uses charged particles (protons or carbon ions) that, due to their peculiar physical properties, permit precise targeting of the tumor with minimal healthy tissue exposure. These characteristics allow for minimizing the potential long-term effects of radiation exposure in terms of neurocognitive impairments, preserving quality of life, and reducing the risk of radio-induced cancer. For these reasons, in children, adolescents, and young adults, proton therapy should be an elective option when available. In radioresistant tumors such as chordomas and sarcomas and previously irradiated recurrent tumors, particle therapy permits the delivery of high biologically effective doses with low, or however acceptable, toxicity. Carbon ion therapy has peculiar and favorable radiobiological characteristics to overcome radioresistance features. In low-grade tumors, proton therapy should be considered in challenging cases due to tumor volume and involvement of critical neural structures. However, particle radiotherapy is still relatively new, and more research is needed to fully understand its effects. Additionally, the availability of particle therapy is limited as it requires specialized equipment and expertise. The purpose of this manuscript is to review the available literature regarding the role of particle radiotherapy in the treatment of skull base tumors.
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Sumodhee S, Atallah V, Kinj R, Doyen J, L'Homel B, Gillon P, Paquis P, Almairac F, Hieronimus S, Schiappa R, Sadoul JL, Sumodhee D, Pontikos N, Richier Q, Hannoun-Levi JM, Scouarnec C, Chevalier N, Bondiau PY. Fractionated Stereotactic Radiation Therapy for Pituitary Adenomas: An alternative escalating protocol of hypofractionated stereotactic radiotherapy delivering 35Gy in 5 fractions. Cancer Radiother 2021; 26:557-562. [PMID: 34711487 DOI: 10.1016/j.canrad.2021.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/03/2021] [Accepted: 08/07/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Evaluate efficacy and toxicity of hypofractionated stereotactic radiotherapy (HSRT) for patients treated for pituitary adenoma (PA) with an alternative HSRT escalating protocol delivering 35Gy in 5 fractions. MATERIAL AND METHODS From June 2007 to March 2017, 29 patients with pituitary adenoma were treated in Antoine Lacassagne Cancer Centre with an alternative HSRT protocol. Prescribed dose was 35Gy in 5 fractions of 7Gy. Radiographic responses were assessed by annual MRI. Hormone blood samples were evaluated each year after HSRT. RESULTS A total of 29 patients aged between 23 and 86 years (median 54 years) were included. Twelve patients received HSRT for recurrent cases and 12 received postoperative adjuvant HSRT, 5 patients did not have surgery. After a median follow-up period of 47 months local control rate was 96%. One patient presented an out-field tumor regrowth 73 months after HSRT. The majority of PA were endocrine-active (18 patients, 62%). After HSRT, 8 patients (44%) presented complete response on initial secretion, 4 patients (23%) presented partial response on initial secretion. Four patients (14%) presented grade 2 or more acute radiation toxicities. One grade 4 visual disorder was observed for one patient. CONCLUSIONS HSRT delivering 35Gy in 5 fractions represents a feasible treatment and shows promising results to reduce hormonal overproduction and to improve local control in PA.
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Affiliation(s)
- S Sumodhee
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France.
| | - V Atallah
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - R Kinj
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - J Doyen
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - B L'Homel
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - P Gillon
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - P Paquis
- Department of Neurosurgery, Centre Hospitalier Universitaire de Nice, Nice, France
| | - F Almairac
- Department of Neurosurgery, Centre Hospitalier Universitaire de Nice, Nice, France
| | - S Hieronimus
- Department of Endocrinology, Centre Hospitalier Universitaire de Nice, Nice, France
| | - R Schiappa
- Department of Biostatistics, Centre Antoine-Lacassagne, Nice, France
| | - J-L Sadoul
- Department of Endocrinology, Centre Hospitalier Universitaire de Nice, Nice, France
| | - D Sumodhee
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College, London, UK
| | - N Pontikos
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Q Richier
- Department of Internal Medicine, CHU de La Réunion, 97400 Saint Denis, France
| | - J-M Hannoun-Levi
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - C Scouarnec
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - N Chevalier
- Department of Neurosurgery, Centre Hospitalier Universitaire de Nice, Nice, France
| | - P-Y Bondiau
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
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HATA A, ODA M, ONO T, SUZUKI A, HANYU N, TAKAHASHI M, SASAJIMA T, HASHIMOTO M, NAKASE T, SHIMIZU H. Long-term Outcomes of Hypofractionated Stereotactic Radiotherapy for the Treatment of Perioptic Nonfunctioning Pituitary Adenomas. Neurol Med Chir (Tokyo) 2021; 61:404-413. [PMID: 33994449 PMCID: PMC8280324 DOI: 10.2176/nmc.oa.2020-0378] [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] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/05/2021] [Indexed: 11/20/2022] Open
Abstract
The efficacy of stereotactic radiotherapy (SRT) has been well established for postoperative residual and recurrent nonfunctioning pituitary adenomas (NFPAs). However, the risk of visual impairment due to SRT for lesions adjacent to the optic pathways remains a topic of debate. Herein, we evaluated the long-term clinical outcomes of hypofractionated stereotactic radiotherapy (HFSRT) for perioptic NFPAs. From December 2002 to November 2015, 32 patients (18 males and 14 females; median age 63 years; range, 36-83 years) with residual or recurrent NFPAs abutting or displacing the optic nerve and/or chiasm (ONC) were treated with HFSRT. The median marginal dose was 31.3 Gy (range, 17.2-39.6) in 8 fractions (range, 6-15). Magnetic resonance imaging (MRI) and visual and hormonal examinations were performed before and after HFSRT. The median follow-up period was 99.5 months (range, 9-191). According to MRI findings at the last follow-up, the tumor size had decreased in 28 (88%) of 32 patients, was unchanged in 3 (9%), and had increased in 1 (3%). The successful tumor size control rate was 97%. Visual functions remained unchanged in 19 (60%) out of 32 patients, improved in 11 (34%), and deteriorated in 2 (6%). Two patients had deteriorated visual functions; no complications occurred because of the HFSRT. One patient developed hypopituitarism that required hormone replacement therapy. The result of this long-term follow-up study suggests that HFSRT is safe and effective for the treatment of NFPAs occurring adjacent to the ONC.
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Affiliation(s)
- Aiko HATA
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
- Department of Stroke Comprehensive Medical Center, Akita University Hospital, Akita, Akita, Japan
| | - Masaya ODA
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Takahiro ONO
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Akira SUZUKI
- Yokohama Tsuoka Noshinkeigeka, Yokohama, Kanagawa, Japan
| | - Noriaki HANYU
- Department of Neurosurgery, Hakodate Shintoshi Hospital, Hakodate, Hokkaido, Japan
| | - Masataka TAKAHASHI
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Toshio SASAJIMA
- Department of Dementia Research, Akita Prefectural Center for Rehabilitation and Psychiatric Medicine, Daisen, Akita, Japan
| | - Manabu HASHIMOTO
- Department of Radiology, Akita University Graduate School of Medicine, Akita, Akita, Japan
| | - Taizen NAKASE
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
- Department of Stroke Comprehensive Medical Center, Akita University Hospital, Akita, Akita, Japan
| | - Hiroaki SHIMIZU
- Department of Neurosurgery, Akita University Graduate School of Medicine, Akita, Akita, Japan
- Department of Stroke Comprehensive Medical Center, Akita University Hospital, Akita, Akita, Japan
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Gamma Knife radiosurgery as the initial treatment for elderly patients with nonfunctioning pituitary adenomas. J Neurooncol 2021; 152:257-264. [PMID: 33638114 DOI: 10.1007/s11060-021-03724-8] [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: 11/11/2020] [Accepted: 12/22/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this study was to investigate the efficacy and safety of initial Gamma Knife radiosurgery (GKRS) for elderly patients with nonfunctioning pituitary adenomas (NFPAs). METHODS We retrospectively reviewed 45 elderly patients underwent GKRS as the initial treatment for NFPAs at our institution between December 2007 and December 2017. Patients' radiographic and clinical data were collected. RESULTS The median age of patients at the time of GKRS was 71 years (range 65-82 years). The median tumor volume was 2.6 cm3 (range 0.3-21.8 cm3). The median marginal dose was 13 Gy (range 6-23 Gy). The median maximum dose to the optic apparatus was 6.5 Gy (range 2.3-10.3 Gy). Thirty-five patients (77.8%) achieved tumor regression, 6 patients (13.3%) had tumor stable and 4 patients (8.9%) occurred tumor progression during a median radiological follow-up time of 51.4 months (range 11.1-158.7 months). The crude tumor control rate was 91.1%. The actuarial tumor control rates were 100%, 95.0%, 87.6%, and 87.6%, at 1, 3, 5, and 10 years after initial GKRS, respectively. New-onset hypopituitarism occurred in 6 patients. Two patients with pre-GKRS visual dysfunction developed further deterioration of visual function. No other radiation-induced complications were noted. CONCLUSION Initial GKRS can provide a high tumor control rate as well as low risk of postradiosurgical complications for elderly patients with NFPAs. Attention should be paid to avoid radiation-related adverse effects including hypopituitarism, optic neuropathy and cranial neuropathy in elderly patients.
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Hsu PW. Fractionated stereotactic radiosurgery in treating the complex intracranial arteriovenous malformations. FORMOSAN JOURNAL OF SURGERY 2021. [DOI: 10.4103/fjs.fjs_88_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Clinical outcomes of fractionated stereotactic radiosurgery in treating perioptic meningiomas and schwannomas: A single-institutional experience. J Clin Neurosci 2020; 81:409-415. [PMID: 33222952 DOI: 10.1016/j.jocn.2020.09.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 09/06/2020] [Accepted: 09/28/2020] [Indexed: 11/24/2022]
Abstract
Application of radiosurgery to the newly diagnosed or post-operative residual perioptic lesions has been proved to improve tumor control. However, risk of vision injury induced by radiosurgery may increase substantially if the radiation dose is too high or tumor is close to the optic apparatus. The purpose of this study was to evaluate the safety and the effectiveness of fractionated stereotactic radiosurgery (FSRS) for perioptic tumors. We retrospectively analyzed 60 consecutive patients with 53 meningiomas and 7 schwannomas treated with FSRS between October 2007 and February 2020. We administered a marginal dose of 6-7 Gy (mean 6.8 Gy) per fraction and delivered 3 fractions in 3 consecutive days. The median tumor volume was 6.31 cm3 (range 0.3-58.23 cm3). The mean minimum lesion-optic distance (MLOD) is 0.85 mm (range 0-3 mm). After mean follow-up period of 69.6 months (range 6.82-156.32 months; median 58.9 months), the tumor control rates at 1, 3, 5, 8 and 13 years were 98.3%, 93.4%, 90.60%, 88.4% and 88.4%, respectively. Four out of the 60 tumors (6.7%) experienced a transient volume increase after FSRS. None of the patients developed visual impairment related to radiation induced optic neuropathy (RION) after FSRS. In conclusion, FSRS offers an alternative treatment option in treating perioptic meningiomas and schwannomas with acceptable tumor control rates and good visual preservation in the present study.
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Khattab MH, Sherry AD, Xu MC, Kelly P, Anderson JL, Luo G, Chambless LB, Cmelak AJ, Attia A. Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy for Nonfunctioning Pituitary Adenoma. J Neurol Surg B Skull Base 2020; 82:e51-e58. [PMID: 34306917 DOI: 10.1055/s-0040-1710518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/14/2020] [Indexed: 10/24/2022] Open
Abstract
Objectives Hypofractionated stereotactic radiotherapy (HSRT) in two to five fractions may offer patients with large nonfunctioning pituitary adenomas (NFPAs) with chiasm involvement a safe and effective treatment over a single week. However, little has been reported regarding this novel approach. Design We compared the feasibility, outcomes, and toxicity of single-fraction stereotactic radiosurgery and HSRT. Setting This study was conducted at a tertiary academic referral center. Participants After approval by the institutional review board, we performed a retrospective cohort study of patients treated at our institution with stereotactic radiosurgery (SRS) and HSRT for NFPA. Selection for SRS or HSRT was based on clinicopathologic factors including tumor size and cavernous sinus invasion at the discretion of the treating physician. Main Outcome Measures Local control, endocrinopathy, and radiation-associated toxicity were evaluated by binary logistic regression and Cox's proportional hazards regression. Results A total of 45 patients with mean follow-up of 5 years were enrolled including 26 patients treated by HSRT with mean follow-up of 3 years and 19 patients treated by SRS with median follow-up of 6 years. Clinicopathologic characteristics were balanced between cohorts. Local failure at last follow-up was 5% in the SRS cohort and 8% in the HSRT cohort, and rates of post-SRS endocrinopathy were similar between each cohort. Late complications including radionecrosis, visual deficit, and secondary malignancy were minimal in either cohort. Conclusions HSRT is an appropriate treatment strategy for patients with NFPAs, particularly for optic pathway preservation in the setting of large tumors with chiasm involvement. Further studies are needed to optimize fractionated approaches and patient selection.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Mark C Xu
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Patrick Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Joshua L Anderson
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Kotecha R, Sahgal A, Rubens M, De Salles A, Fariselli L, Pollock BE, Levivier M, Ma L, Paddick I, Regis J, Sheehan J, Yomo S, Suh JH. Stereotactic radiosurgery for non-functioning pituitary adenomas: meta-analysis and International Stereotactic Radiosurgery Society practice opinion. Neuro Oncol 2020; 22:318-332. [PMID: 31790121 PMCID: PMC7058447 DOI: 10.1093/neuonc/noz225] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND This systematic review reports on outcomes and toxicities following stereotactic radiosurgery (SRS) for non-functioning pituitary adenomas (NFAs) and presents consensus opinions regarding appropriate patient management. METHODS Using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic review was performed from articles of ≥10 patients with NFAs published prior to May 2018 from the Medline database using the key words "radiosurgery" and "pituitary" and/or "adenoma." Weighted random effects models were used to calculate pooled outcome estimates. RESULTS Of the 678 abstracts reviewed, 35 full-text articles were included describing the outcomes of 2671 patients treated between 1971 and 2017 with either single fraction SRS or hypofractionated stereotactic radiotherapy (HSRT). All studies were retrospective (level IV evidence). SRS was used in 27 studies (median dose: 15 Gy, range: 5-35 Gy) and HSRT in 8 studies (median total dose: 21 Gy, range: 12-25 Gy, delivered in 3-5 fractions). The 5-year random effects local control estimate after SRS was 94% (95% CI: 93.0-96.0%) and 97.0% (95% CI: 93.0-98.0%) after HSRT. The 10-year local control random effects estimate after SRS was 83.0% (95% CI: 77.0-88.0%). Post-SRS hypopituitarism was the most common treatment-related toxicity observed, with a random effects estimate of 21.0% (95% CI: 15.0-27.0%), whereas visual dysfunction or other cranial nerve injuries were uncommon (range: 0-7%). CONCLUSIONS SRS is an effective and safe treatment for patients with NFAs. Encouraging short-term data support HSRT for select patients, and mature outcomes are needed before definitive recommendations can be made. Clinical practice opinions were developed on behalf of the International Stereotactic Radiosurgery Society (ISRS).
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Muni Rubens
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Antonio De Salles
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Laura Fariselli
- Radiotherapy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Marc Levivier
- Department of Neurosurgery and Gamma Knife Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Ian Paddick
- Medical Physics Ltd, Reading, Cromwell Hospital, London, UK
| | - Jean Regis
- Functional and Stereotaxic Neurosurgery Department, Clinical Neuroscience Federation, Timone Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, 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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Sherry AD, Khattab MH, Xu MC, Kelly P, Anderson JL, Luo G, Utz AL, Chambless LB, Cmelak AJ, Attia A. Outcomes of stereotactic radiosurgery and hypofractionated stereotactic radiotherapy for refractory Cushing's disease. Pituitary 2019; 22:607-613. [PMID: 31552580 DOI: 10.1007/s11102-019-00992-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE Hypofractionated stereotactic radiotherapy (HSRT) for refractory Cushing's disease may offer a condensed treatment schedule for patients with large tumors abutting the optic chiasm unsuitable for stereotactic radiosurgery (SRS). To-date only four patients have been treated by HSRT in the published literature. We investigated the feasibility, toxicity, and efficacy of HSRT compared to SRS. METHODS After approval, we retrospectively evaluated patients treated at our institution for refractory Cushing's disease with SRS or HSRT. Study outcomes included biochemical control, time to biochemical control, local control, and late complications. Binary logistic regression and Cox proportional hazards regression evaluated predictors of outcomes. RESULTS Patients treated with SRS (n = 9) and HSRT (n = 9) were enrolled with median follow-up of 3.4 years. Clinicopathologic details were balanced between the cohorts. Local control was 100% in both cohorts. Time to biochemical control was 6.6. and 9.5 months in the SRS and HSRT cohorts, respectively (p = 0.6258). Two patients in each cohort required salvage bilateral adrenalectomy. Late complications including secondary malignancy, radionecrosis, cranial nerve neuropathy, and optic pathway injury were minimal for either cohort. CONCLUSIONS HSRT is an appropriate treatment approach for refractory Cushing's disease, particularly for patients with large tumors abutting the optic apparatus. Prospective studies are needed to validate these findings and identify factors suggesting optimal fractionation approaches.
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Affiliation(s)
| | - Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA.
| | - Mark C Xu
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Patrick Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
| | - Andrea L Utz
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Division of Diabetes, Endocrinology & Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Pituitary Center, Nashville, TN, USA
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, 2220 Pierce Avenue, Preston Research Building, Rm B-1003, Nashville, TN, 37232-5671, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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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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Albano L, Losa M, Nadin F, Barzaghi LR, Parisi V, Del Vecchio A, Bolognesi A, Mortini P. Safety and efficacy of multisession gamma knife radiosurgery for residual or recurrent pituitary adenomas. Endocrine 2019; 64:639-647. [PMID: 30798432 DOI: 10.1007/s12020-019-01876-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/16/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To define the efficacy and complications of multisession Gamma Knife radiosurgery (MGKRS) delivered in three consecutive sessions for the treatment of residual or recurrent pituitary adenomas (PAs). METHODS This was a retrospective study of data from the Neurosurgery and Gamma Knife Radiosurgery Department at San Raffaele Hospital between May 2008 and September 2017. We recruited 47 consecutive patients undergoing MGKRS in three consecutive fractions for residual or recurrent PA with a distance from the anterior optic pathway inferior to 2-3 mm. RESULTS Thirty-eight (80.8%) patients had a nonfunctioning-PA (NFPA) while 9 (19.2%) had a hormone-secreting PA (HSPA). Tumor control was achieved in 100% of patients. Tumor shrinkage was seen in 33 out of 44 (75.0%) patients with a radiological follow-up. Mean tumor volume before MGKRS was 3.93 cm3. The mean tumor volume at last follow-up was 2.11 cm3, with a mean tumor shrinkage of 50.2%, as compared with baseline. One case of suspected radiation-induced optic neuropathy (RION) was documented while new-onset hypopituitarism for any axis occurred in 12 of the 31 (38.7%) patients at risk. The mean follow-up was 44.6 ± 4.0 months (range, 6-111 months). CONCLUSIONS MGKRS is a valid alternative to external fractionated radiotherapy and other types of stereotactic radiosurgery for the treatment of PAs, achieving a high tumor control rate with a low risk of visual deterioration. Moreover, the majority of patients showed a significant reduction of tumor size in the long term.
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Affiliation(s)
- Luigi Albano
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Francesco Nadin
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lina Raffaella Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Veronica Parisi
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Antonella Del Vecchio
- Department of Medical Physics, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Angelo Bolognesi
- Department of Radiation therapy, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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Abstract
Radiation therapy (RT) is an effective treatment for patients with either nonfunctioning or secreting pituitary adenomas unsuccessfully treated by surgery and/or medical therapy, resulting in local control of 90-95% at 5-10 years and variable normalization of hormonal hypersecretion for patients with GH-, ACTH-, and prolactin-secreting adenomas in the range of 40-80% at 5 years; however, its use has been limited because of concerns regarding potential late toxicity of radiation and delayed efficacy in normalization of hormone hypersecretion. In the last decades, there have been advances in all aspects of radiation treatment, including more accurate immobilization, imaging, treatment planning and dose delivery. RT has evolved with the development of highly conformal stereotactic techniques and new planning and dose delivery techniques, including intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT). All these new techniques allow precise and sharply focused radiation delivery reducing the dose to surrounding critical neurovascular and brain structures, and potentially limiting the long-term consequences of radiation treatments. In this review, we present a critical analysis of the more recent available literature on the use of RT in patients with both nonfunctioning and secreting pituitary adenomas, focussing particularly on the risk/benefit ratio of modern radiation techniques.
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Affiliation(s)
- Giuseppe Minniti
- Radiation Unit, UPMC Hillman Cancer Center, San Pietro Hospital, Rome, Italy.
| | - John Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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14
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Clinical outcomes of perioptic tumors treated with hypofractionated stereotactic radiotherapy using CyberKnife® stereotactic radiosurgery. J Neurooncol 2018; 139:679-688. [DOI: 10.1007/s11060-018-2913-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 05/25/2018] [Indexed: 12/30/2022]
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Abstract
External beam radiotherapy (RT) is an essential part of the management of intracranial tumors and has been used in treating pituitary adenomas for more than five decades. It has been demonstrated that conventional RT for postoperative residual or progressive nonfunctioning pituitary adenomas (NFAs) present an excellent long-term local tumor control, although its use has been limited because of the potential late toxicity related to radiation treatments. Recent advances in radiation techniques have led to more accurate treatments, rendering obsolete many commonly held views of the "old" radiotherapy. New techniques include intensity modulated radiotherapy, volumetric-modulated arc therapy, and stereotactic techniques, either stereotactic radiosurgery or fractionated stereotactic radiotherapy. New techniques allow the delivering of higher radiation doses to the target with rapid dose fall-off in the surrounding normal tissues, and potentially limiting the long term toxicity of radiation. In this review, we present a critical analysis of the most recent available literature on the use of radiation in patients with NFAs, focusing particularly on the efficacy and safety of radiation stereotactic techniques.
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Affiliation(s)
- Giuseppe Minniti
- UPMC San Pietro FBF, Rome, Italy.
- IRCCS Neuromed, 86077, Pozzilli, IS, Italy.
| | - John Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Milano MT, Grimm J, Soltys SG, Yorke E, Moiseenko V, Tomé WA, Sahgal A, Xue J, Ma L, Solberg TD, Kirkpatrick JP, Constine LS, Flickinger JC, Marks LB, El Naqa I. Single- and Multi-Fraction Stereotactic Radiosurgery Dose Tolerances of the Optic Pathways. Int J Radiat Oncol Biol Phys 2018. [PMID: 29534899 DOI: 10.1016/j.ijrobp.2018.01.053] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Dosimetric and clinical predictors of radiation-induced optic nerve/chiasm neuropathy (RION) after single-fraction stereotactic radiosurgery (SRS) or hypofractionated (2-5 fractions) radiosurgery (fSRS) were analyzed from pooled data that were extracted from published reports (PubMed indexed from 1990 to June 2015). This study was undertaken as part of the American Association of Physicists in Medicine Working Group on Stereotactic Body Radiotherapy, investigating normal tissue complication probability (NTCP) after hypofractionated radiation. METHODS AND MATERIALS Eligible studies described dose delivered to optic nerve/chiasm and provided crude or actuarial toxicity risks, with visual endpoints (ie, loss of visual acuity, alterations in visual fields, and/or blindness/complete vision loss). Studies of patients with optic nerve sheath tumors, optic nerve gliomas, or ocular/uveal melanoma were excluded to obviate direct tumor effects on visual outcomes, as were studies not specifying causes of vision loss (ie, tumor progression vs RION). RESULTS Thirty-four studies (1578 patients) were analyzed. Histologies included pituitary adenoma, cavernous sinus meningioma, craniopharyngioma, and malignant skull base tumors. Prior resection (76% of patients) did not correlate with RION risk (P = .66). Prior irradiation (6% of patients) was associated with a crude 10-fold increased RION risk versus no prior radiation therapy. In patients with no prior radiation therapy receiving SRS/fSRS in 1-5 fractions, optic apparatus maximum point doses resulting in <1% RION risks include 12 Gy in 1 fraction (which is greater than our recommendation of 10 Gy in 1 fraction), 20 Gy in 3 fractions, and 25 Gy in 5 fractions. Omitting multi-fraction data (and thereby eliminating uncertainties associated with dose conversions), a single-fraction dose of 10 Gy was associated with a 1% RION risk. Insufficient details precluded modeling of NTCP risks after prior radiation therapy. CONCLUSIONS Optic apparatus NTCP and tolerance doses after single- and multi-fraction stereotactic radiosurgery are presented. Additional standardized dosimetric and toxicity reporting is needed to facilitate future pooled analyses and better define RION NTCP after SRS/fSRS.
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Affiliation(s)
- Michael T Milano
- Department of Radiation Oncology, University of Rochester, Rochester, New York.
| | - Jimm Grimm
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, California
| | - Ellen Yorke
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vitali Moiseenko
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla, California
| | - Wolfgang A Tomé
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York
| | - Arjun Sahgal
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jinyu Xue
- Department of Radiation Oncology, NYU Langone Medical Center, New York, New York
| | - Lijun Ma
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - Timothy D Solberg
- Department of Radiation Oncology, University of California, San Francisco, San Francisco, California
| | - John P Kirkpatrick
- Departments of Radiation Oncology and Surgery, Duke Cancer Institute, Durham, North Carolina
| | - Louis S Constine
- Department of Radiation Oncology, University of Rochester, Rochester, New York
| | - John C Flickinger
- Departments of Radiation Oncology and Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Issam El Naqa
- Department of Radiation Oncology, Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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Barber SM, Teh BS, Baskin DS. Fractionated Stereotactic Radiotherapy for Pituitary Adenomas: Single-Center Experience in 75 Consecutive Patients. Neurosurgery 2017; 79:406-17. [PMID: 26657072 DOI: 10.1227/neu.0000000000001155] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Early results of postoperative fractionated stereotactic radiotherapy (FSRT) for functional and nonfunctional pituitary adenomas appear promising, but the majority of available evidence draws from small series with insufficient follow-up data to draw meaningful conclusions. OBJECTIVE To evaluate the long-term outcomes of a large series of patients undergoing FSRT for both functional and nonfunctional pituitary adenomas with the Novalis system (BrainLAB, Heimstetten, Germany). METHODS Chart data for 75 consecutive patients undergoing FSRT for a pituitary tumor (21 functional and 54 nonfunctional adenomas) at our institution between January 2004 and June 2013 were reviewed. RESULTS Radiographic progression-free survival was 100% over a mean of 47.8 months of radiographic follow-up (range, 12.0-131.2 months). Hormonal normalization was seen in 69.2% of patients with functional adenomas after FSRT, whereas 30.8% experienced partial hormonal control. Mild, grade I acute adverse effects were observed during radiotherapy treatment in 36 patients (48%), and objective, persistent worsening of vision occurred in a single patient (1.5%) after FSRT. New hormonal deficits were seen in 28.0% of patients after FSRT. Radiographic responses were inversely related to tumor volume. CONCLUSION FSRT delivers radiographic and functional outcomes similar to those seen with stereotactic radiosurgery and conventional radiotherapy with less resultant toxicity. FSRT is most beneficial for smaller tumors (those <3 cm in diameter). ABBREVIATIONS EBRT, external beam radiotherapyFSRT, fractionated stereotactic radiotherapyOR, odds ratioPTV, planning target volumeSRS, stereotactic radiosurgery.
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Affiliation(s)
- Sean M Barber
- *Houston Methodist Neurological Institute, Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; ‡Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas; §Kenneth R. Peak Brain and Pituitary Tumor Treatment Center, Houston Methodist Hospital, Houston, Texas
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18
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Abstract
Purpose Treatment of acromegaly has undergone important progress in the last 20 years mainly due to the development of new medical options and advances in surgical techniques. Pituitary surgery is usually first-line therapy, and medical treatment is indicated for persistent disease, while radiation (RT) is often used as third-line therapy. The benefits of RT (tumor volume control and decreased hormonal secretion) are hampered by the long latency of the effect and the high risk of adverse effects. Stereotactic RT methods have been developed with the aim to provide more precise targeting of the tumor with better control of the radiation dose received by the adjacent brain structures. The purpose of this review is to present the updates in the efficacy and safety of pituitary RT in acromegalic patients, with an emphasis on the new stereotactic radiation techniques. Methods A systematic review was performed using PubMed and articles/abstracts and reviews detailing RT in acromegaly from 2000 to 2016 were included. Results Stereotactic radiosurgery and fractionated stereotactic RT (FSRT) for patients with persistent active acromegaly after surgery and/or during medical therapy provide comparable high rates of tumor control, i.e. stable or decrease in size of the tumor in 93-100% of patients at 5-10 years and endocrinological remission in 40-60% of patients at 5 years. Hypofractionated RT is an optimal option for tumors located near the optic structures, due to its lower toxicity for the optic nerves compared to single-dose radiosurgery. The rate of new hypopituitarism varies from 10 to 50% at 5 years and increases with the duration of follow-up. The risk for other radiation-induced complications is usually low (0-5% for new visual deficits, cranial nerves damage or brain radionecrosis and 0-1% for secondary brain tumors) and risk of stroke may be higher in FSRT. Conclusion Although the use of radiotherapy in patients with acromegaly has decreased with advances in medical treatments, it remains an effective treatment option after unsuccessful surgery and/or resistance or unavailability of medical therapy. Long-term studies evaluating secondary morbidity and mortality rate after the new stereotactic techniques are needed, in order to evaluate their potential brain-sparing effect.
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Affiliation(s)
- Monica Livia Gheorghiu
- C.I. Parhon" National Institute of Endocrinology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
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19
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Gheorghiu ML, Fleseriu M. STEREOTACTIC RADIATION THERAPY IN PITUITARY ADENOMAS, IS IT BETTER THAN CONVENTIONAL RADIATION THERAPY? ACTA ENDOCRINOLOGICA-BUCHAREST 2017; 13:476-490. [PMID: 31149219 DOI: 10.4183/aeb.2017.476] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Pituitary radiotherapy (RT) has undergone important progress in the last decades due to the development of new stereotactic techniques which provide more precise tumour targeting with less overall radiation received by the adjacent brain structures. Pituitary surgery is usually first-line therapy in most patients with nonfunctioning (NFPA) and functioning adenomas (except for prolactinomas and large growth hormone (GH) secreting adenomas), while RT is used as second or third-line therapy. The benefits of RT (tumour volume control and, in functional tumours, decreased hormonal secretion) are hampered by the long latency of the effect and the potential side effects. This review presents the updates in the efficacy and safety of the new stereotactic radiation techniques in patients with NFPA, GH-, ACTH- or PRL-secreting pituitary adenomas. Methods A systematic review was performed using PubMed and articles/abstracts and reviews detailing RT in pituitary adenomas from 2000 to 2017 were included. Results Stereotactic radiosurgery (SRS) and fractionated stereotactic RT (FSRT) provide high rates of tumour control i.e. stable or decrease in tumour size, in all types of pituitary adenomas (median 92 - 98%) at 5 years. Endocrinological remission is however significantly lower: 44-52% in acromegaly, 54-64% in Cushing's disease and around 30% in prolactinomas at 5 years. The rate of new hypopituitarism varies from 10% to 50% at 5 years in all tumour types and as expected increases with the duration of follow-up (FU). The risk for other radiation-induced complications is usually low (0-5% for new visual deficits, cranial nerves damage or brain radionecrosis and extremely low for secondary brain tumours), however longer FU is needed to determine rates of secondary tumours. Notably, in acromegaly, there may be a higher risk for stroke with FSRT. Conclusion Stereotactic radiotherapy can be an effective treatment option for patients with persistent or recurrent pituitary adenomas after unsuccessful surgery (especially if residual tumour is enlarging) and/or resistance or unavailability of medical therapy. Comparison with conventional radiation therapy (CRT) is rather difficult, due to the substantial heterogeneity of the studies. In order to evaluate the potential brain-sparing effect of the new stereotactic techniques, suggested by the current data, long-term studies evaluating secondary morbidity and mortality are needed.
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Affiliation(s)
- M L Gheorghiu
- "Carol Davila" University of Medicine and Pharmacy, "C.I. Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - M Fleseriu
- Oregon Health & Science University, Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Portland, USA
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Safety and efficacy of fractionated stereotactic radiotherapy and stereotactic radiosurgery for treatment of pituitary adenomas: A systematic review and meta-analysis. J Neurol Sci 2016; 372:110-116. [PMID: 28017195 DOI: 10.1016/j.jns.2016.11.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 11/11/2016] [Accepted: 11/13/2016] [Indexed: 01/11/2023]
Abstract
Accumulated studies have not provided conclusive evidence in regards to the comparative efficacy and safety of fractionated stereotactic radiotherapy and stereotactic radiosurgery for treatment of pituitary adenomas. To address this issue, we performed a meta-analysis with eight studies identified from Medline, PubMed, Cochrane, Google Scholar, and published up to September 17, 2015. Eligible studies reported the disease control rate, endocrine cure rate (for functional adenomas), the rate of occurrence of new-onset hypopituitarism, and visual disturbance rate in patients treated with either stereotactic radiosurgery or fractionated stereotactic radiotherapy. Eight studies enrolled a total of 634 patients with pituitary adenoma, 273 patients underwent a stereotactic radiosurgery and 361 patients underwent fractionated stereotactic radiotherapy. No significant differences were found in efficacy measures, such as disease control rate and endocrine cure rate, between stereotactic radiosurgery and fractionated stereotactic radiotherapy (OR=1.156, p=0.666; OR=0.659, p=0.153, respectively). Additionally, meta-analysis of safety measures, such as the rate of new-onset hypopituitarism and visual disturbance rate, did not show significant differences between different treatments (OR=1.365, p=0.469; OR=0.872, p=0.845 respectively). In conclusion, both stereotactic radiosurgery and fractionated stereotactic radiotherapy have comparable efficacy and safety in the management of pituitary adenoma patients.
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Minniti G, Osti MF, Niyazi M. Target delineation and optimal radiosurgical dose for pituitary tumors. Radiat Oncol 2016; 11:135. [PMID: 27729088 PMCID: PMC5057503 DOI: 10.1186/s13014-016-0710-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 10/01/2016] [Indexed: 11/10/2022] Open
Abstract
Stereotactic radiosurgery (SRS) delivered as either single-fraction or multi-fraction SRS (2–5 fractions) is frequently employed in patients with residual or recurrent pituitary adenoma. The most common delivery systems used for SRS include the cobalt-60 system Gamma Knife, the CyberKnife (CK) robotic radiosurgery system, or a modified conventional radiotherapy machine (linear accelerator, LINAC). Tumor control and normalization of hormone hypersecretion have been reported in 75–100 % and 25–80 % of patients, respectively. Hypopituitarism is the most commonly reported late complication of radiation treatment, whereas other toxicities occur less frequently. We have provided an overview of the recent available literature on SRS in patients with a pituitary adenoma. Critical aspects of pituitary irradiation, including target delineation and doses to organs at risk, optimal radiation dose, as well as the long-term efficacy and toxicity of SRS for either nonfunctioning or secreting pituitary adenomas are discussed. Single-fraction SRS represents an effective treatment for patients with a pituitary adenoma; however, caution should be used for lesions > 2.5–3 cm in size and/or involving the anterior optic pathway. Future studies will be necessary to optimize target doses and critical organ dose constrains in order to reduce the long-term toxicity of treatments while maintaining high efficacy.
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Affiliation(s)
- Giuseppe Minniti
- Unit of Radiation Oncology, Sant' Andrea Hospital, University Sapienza, Rome, Italy. .,IRCCS Neuromed, Pozzilli (IS), Italy.
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Keeling V, Hossain S, Jin H, Algan O, Ahmad S, Ali I. Quantitative evaluation of patient setup uncertainty of stereotactic radiotherapy with the frameless 6D ExacTrac system using statistical modeling. J Appl Clin Med Phys 2016; 17:111-127. [PMID: 27167267 PMCID: PMC5690915 DOI: 10.1120/jacmp.v17i3.5959] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 01/18/2016] [Accepted: 01/11/2016] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study is to evaluate patient setup accuracy and quantify individual and cumulative positioning uncertainties associated with different hardware and software components of the stereotactic radiotherapy (SRS/SRT) with the frameless 6D ExacTrac system. A statistical model is used to evaluate positioning uncertainties of the different components of SRS/SRT treatment with the Brainlab 6D ExacTrac system using the positioning shifts of 35 patients having cranial lesions. All these patients are immobilized with rigid head‐and‐neck masks, simulated with Brainlab localizer and planned with iPlan treatment planning system. Stereoscopic X‐ray images (XC) are acquired and registered to corresponding digitally reconstructed radiographs using bony‐anatomy matching to calculate 6D translational and rotational shifts. When the shifts are within tolerance (0.7 mm and 1°), treatment is initiated. Otherwise corrections are applied and additional X‐rays (XV) are acquired to verify that patient position is within tolerance. The uncertainties from the mask, localizer, IR ‐frame, X‐ray imaging, MV, and kV isocentricity are quantified individually. Mask uncertainty (translational: lateral, longitudinal, vertical; rotational: pitch, roll, yaw) is the largest and varies with patients in the range (−2.07−3.71mm,−5.82−5.62mm,−5.84−3.61mm;−2.10−2.40∘,−2.23−2.60∘,and−2.7−3.00∘) obtained from mean of XC shifts for each patient. Setup uncertainty in IR positioning (0.88, 2.12, 1.40 mm, and 0.64°, 0.83°, 0.96°) is extracted from standard deviation of XC. Systematic uncertainties of the frame (0.18, 0.25, −1.27mm, −0.32∘, 0.18°, and 0.47°) and localizer (−0.03, −0.01, 0.03 mm, and −0.03∘, 0.00°, −0.01∘) are extracted from means of all XV setups and mean of all XC distributions, respectively. Uncertainties in isocentricity of the MV radiotherapy machine are (0.27, 0.24, 0.34 mm) and kV imager (0.15, −0.4, 0.21 mm). A statistical model is developed to evaluate the individual and cumulative systematic and random positioning uncertainties induced by the different hardware and software components of the 6D ExacTrac system. The uncertainties from the mask, localizer, IR frame, X‐ray imaging, couch, MV linac, and kV imager isocentricity are quantified using statistical modeling. PACS number(s): 87.56.B‐, 87.59.B‐
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Affiliation(s)
- Vance Keeling
- Stephenson Oklahoma Cancer Center; University of Oklahoma Health Sciences Center.
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Hiniker SM, Modlin LA, Choi CY, Atalar B, Seiger K, Binkley MS, Harris JP, Liao YJ, Fischbein N, Wang L, Ho A, Lo A, Chang SD, Harsh GR, Gibbs IC, Hancock SL, Li G, Adler JR, Soltys SG. Dose-Response Modeling of the Visual Pathway Tolerance to Single-Fraction and Hypofractionated Stereotactic Radiosurgery. Semin Radiat Oncol 2016; 26:97-104. [DOI: 10.1016/j.semradonc.2015.11.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Jin H, Keeling VP, Ali I, Ahmad S. Dosimetric effects of positioning shifts using 6D-frameless stereotactic Brainlab system in hypofractionated intracranial radiotherapy. J Appl Clin Med Phys 2016; 17:102-111. [PMID: 26894336 PMCID: PMC5690222 DOI: 10.1120/jacmp.v17i1.5682] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 08/19/2015] [Accepted: 08/03/2015] [Indexed: 11/23/2022] Open
Abstract
Dosimetric consequences of positional shifts were studied using frameless Brainlab ExacTrac X‐ray system for hypofractionated (3 or 5 fractions) intracranial stereotactic radiotherapy (SRT). SRT treatments of 17 patients with metastatic intracranial tumors using the stereotactic system were retrospectively investigated. The treatments were simulated in a treatment planning system by modifying planning parameters with a matrix conversion technique based on positional shifts for initial infrared (IR)‐based setup (XC: X‐ray correction) and post‐correction (XV: X‐ray verification). The simulation was implemented with (a) 3D translational shifts only and (b) 6D translational and rotational shifts for dosimetric effects of angular correction. Mean translations and rotations (± 1 SD) of 77 fractions based on the initial IR setup (XC) were 0.51±0.86 mm (lateral), 0.30±1.55 mm (longitudinal), and −1.63±1.00 mm (vertical); 0.53±0.56 mm (pitch), 0.42±0.60 mm (roll), and 0.44±0.90 mm (yaw), respectively. These were −0.07±0.24 mm, −0.07±0.25 mm, 0.06±0.21 mm, 0.04±0.23 mm, 0.00±0.30 mm, and 0.02±0.22 mm, respectively, for the postcorrection (XV). Substantial degradation of the treatment plans was observed in D95 of PTV (2.6%±3.3%; simulated treatment versus treatment planning), Dmin of PTV (13.4%±11.6%), and Dmin of CTV (2.8%±3.8%, with the maximum error of 10.0%) from XC, while dosimetrically negligible changes (< 0.1%) were detected for both CTV and PTV from XV simulation. 3D angular correction significantly improved CTV dose coverage when the total angular shifts (|pitch|+|roll|+|yaw|) were greater than 2°. With the 6D stereoscopic X‐ray verification imaging and frameless immobilization, submillimeter and subdegree accuracy is achieved with negligible dosimetric deviations. 3D angular correction is required when the angular deviation is substantial. A CTV‐to‐PTV safety margin of 2 mm is large enough to prevent deterioration of CTV coverage. PACS number: 87.55.dk
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Affiliation(s)
- Hosang Jin
- University of Oklahoma Health Sciences Center.
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Puataweepong P, Dhanachai M, Hansasuta A, Dangprasert S, Swangsilpa T, Sitathanee C, Jiarpinitnun C, Vitoonpanich P, Yongvithisatid P. The Clinical Outcome of Hypofractionated Stereotactic Radiotherapy With CyberKnife Robotic Radiosurgery for Perioptic Pituitary Adenoma. Technol Cancer Res Treat 2015; 15:NP10-NP15. [PMID: 26424501 DOI: 10.1177/1533034615607113] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/24/2015] [Accepted: 08/17/2015] [Indexed: 11/17/2022] Open
Abstract
Stereotactic radiation technique including single fraction radiosurgery and conventional fractionated stereotactic radiotherapy is widely reported as an effective treatment of pituitary adenomas. Because of the restricted radiation tolerance dose of the optic pathway, single fraction radiosurgery has been accepted for small tumor located far away from the optic apparatus, while fractionated stereotactic radiotherapy may be suitable for larger tumor located close to the optic pathway. More recently, hypofractionated stereotactic radiotherapy has become an alternative treatment option that provides high rate of tumor control and visual preservation for the perioptic lesions within 2 to 3 mm of the optic pathway. The objective of the study was to analyze the clinical outcomes of perioptic pituitary adenomas treated with hypofractionated stereotactic radiotherapy. From 2009 to 2012, 40 patients with perioptic pituitary adenoma were treated with CyberKnife robotic radiosurgery. The median tumor volume was 3.35 cm3 (range, 0.82-25.86 cm3). The median prescribed dose was 25 Gy (range, 20-28 Gy) in 5 fractions (range, 3-5). After the median follow-up time of 38.5 months (range, 14-71 months), 1 (2.5%) patient with prolactinoma had tumor enlargement, 31 (77.5%) were stable, and the remaining 8 (20%) tumors were smaller in size. No patient's vision deteriorated after hypofractionated stereotactic radiotherapy. Hormone normalization was observed in 7 (54%) of 13 patients. No newly developed hypopituitarism was detected in our study. These data confirmed that hypofractionated stereotactic radiotherapy achieved high rates of tumor control and visual preservation. Because of the shorter duration of treatment, it may be preferable to use hypofractionated stereotactic radiotherapy over fractionated stereotactic radiotherapy for selected pituitary adenomas immediately adjacent to the optic apparatus.
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Affiliation(s)
- Putipun Puataweepong
- Radiation and Oncology Unit, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Mantana Dhanachai
- Radiation and Oncology Unit, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ake Hansasuta
- Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Somjai Dangprasert
- Radiation and Oncology Unit, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thiti Swangsilpa
- Radiation and Oncology Unit, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chomporn Sitathanee
- Radiation and Oncology Unit, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chuleeporn Jiarpinitnun
- Radiation and Oncology Unit, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Patamintita Vitoonpanich
- Radiation and Oncology Unit, Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pornpan Yongvithisatid
- Radiosurgery Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Puataweepong P, Dhanachai M, Hansasuta A, Dangprasert S, Sitathanee C, Swangsilpa T, Vitoonpanich P, Yongvithisatid P. Outcomes for Pituitary Adenoma Patients Treated with Linac-Based Stereotactic Radiosurgery and Radiotherapy: a Long Term Experience in Thailand. Asian Pac J Cancer Prev 2015. [DOI: 10.7314/apjcp.2015.16.13.5279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Minniti G, Scaringi C, Poggi M, Jaffrain Rea ML, Trillò G, Esposito V, Bozzao A, Enrici MM, Toscano V, Enrici RM. Fractionated stereotactic radiotherapy for large and invasive non-functioning pituitary adenomas: long-term clinical outcomes and volumetric MRI assessment of tumor response. Eur J Endocrinol 2015; 172:433-41. [PMID: 25627653 DOI: 10.1530/eje-14-0872] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We describe the use of fractionated stereotactic radiotherapy (FSRT) for the treatment of large, invasive, nonfunctioning pituitary adenomas (NFPAs). FSRT is frequently employed for the treatment of residual or recurrent pituitary adenomas. PATIENTS AND METHODS Sixty-eight patients with a large residual or recurrent NFPAs were treated between April 2004 and December 2012, including 39 males and 29 females (median age 51 years). Visual defects were present in 34 patients, consisting of visual field defects (n=31) and/or reduced visual acuity (n=12). Forty-five patients had evidence of partial or total hypopituitarism before FSRT. For most of the patients, the treatment was delivered through 5-10 noncoplanar conformal fixed fields using a 6-MV linear accelerator to a dose of 45 Gy in 25 fractions. RESULTS At a median follow-up of 75 months (range 12-120 months), the 5- and 10-year actuarial local control were 97 and 91%, respectively, and overall survival 97 and 93%, respectively. Forty-nine patients had a tumor reduction, 16 remained stable, and three progressed. The relative tumor volume reduction measured using three-dimensional (3D) magnetic resonance imaging (MRI) was 47%. The treatment was well tolerated with minimal acute toxicity. Eighteen patients developed partial or complete hypopituitarism. The actuarial incidence of new anterior pituitary deficits was 40% at 5 years and 72% at 10 years. No other radiation-induced complications occurred. CONCLUSIONS Our results suggest that FSRT is an effective treatment for large or giant pituitary adenomas with low toxicity.
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Affiliation(s)
- Giuseppe Minniti
- Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy
| | - Claudia Scaringi
- Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy
| | - Maurizio Poggi
- Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy
| | - Marie Lise Jaffrain Rea
- Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy
| | - Giuseppe Trillò
- Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy
| | - Vincenzo Esposito
- Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy
| | - Alessandro Bozzao
- Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy
| | - Maurizio Maurizi Enrici
- Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy
| | - Vincenzo Toscano
- Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy
| | - Riccardo Maurizi Enrici
- Radiation Oncology UnitSant' Andrea Hospital, University Sapienza, Via di Grottarossa 1035, 00189 Rome, ItalyIRCCS NeuromedPozzilli, Isernia, ItalyEndocrinology UnitNeurosurgery UnitNeuroradiology UnitOphthalmology UnitSant' Andrea Hospital, University Sapienza, Rome, Italy
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Minniti G, Clarke E, Scaringi C, Enrici RM. Stereotactic radiotherapy and radiosurgery for non-functioning and secreting pituitary adenomas. Rep Pract Oncol Radiother 2014; 21:370-8. [PMID: 27330422 DOI: 10.1016/j.rpor.2014.09.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/28/2014] [Accepted: 09/16/2014] [Indexed: 11/18/2022] Open
Abstract
Radiotherapy (RT) is frequently employed in patients with residual or recurrent pituitary adenoma with excellent rates of tumor control and remission of hormonal hypersecretion. Advances in RT have improved with the use of stereotactic techniques either as fractionated stereotactic radiotherapy (FSRT) or stereotactic radiosurgery (SRS), all aiming to improve the dose distribution to the tumor while reducing the amount of normal brain receiving significant doses of radiation. We provide an overview of the recent published literature on the long-term efficacy and adverse effects of stereotactic irradiation in nonfunctioning and secreting pituitary adenomas. Both techniques are associated with excellent clinical outcomes; however, advantages and drawbacks of each of these techniques in terms of local control, hormonal excess normalization, and radiation-induced toxicity remain a matter of debate. In clinical practice, single-fraction SRS may represent a convenient approach to patients with small and medium-sized pituitary adenoma away at least 2 mm from the optic chiasm, whereas FSRT is preferred over SRS for lesions >2.5-3 cm in size and/or involving the anterior optic pathway.
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Affiliation(s)
- Giuseppe Minniti
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy
| | - Enrico Clarke
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Claudia Scaringi
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Riccardo Maurizi Enrici
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
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Lee CC, Chen CJ, Yen CP, Xu Z, Schlesinger D, Fezeu F, Sheehan JP. Whole-Sellar Stereotactic Radiosurgery for Functioning Pituitary Adenomas. Neurosurgery 2014; 75:227-37; discussion 237. [DOI: 10.1227/neu.0000000000000425] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Functioning pituitary adenomas (FPAs) can be difficult to delineate on postoperative magnetic resonance imaging, making them difficult targets for stereotactic radiosurgery (SRS). In such cases, radiation delivery to the entire sella has been utilized as a radiosurgical equivalent of a total hypophysectomy.
OBJECTIVE:
To evaluate the outcomes of a cohort of patients with FPA who underwent SRS to the whole-sellar region.
METHODS:
This is a retrospective review of patients who underwent whole-sellar SRS for FPA between 1989 and 2012. Sixty-four patients met the inclusion criteria: they were treated with whole-sellar SRS following surgical resection for persistently elevated hormone levels, and (1) no visible lesions on imaging studies and/or (2) tumor infiltration of dura or adjacent venous sinuses observed at the time of a prior resection. The median radiosurgical volume covering sellar structures was 3.2 mL, with a median margin dose of 25 Gy.
RESULTS:
The median endocrine follow-up was 41 months; 22 (68.8%) patients with acromegaly, 20 (71.4%) patients with Cushing disease, and 2 (50.0%) patients with prolactinoma achieved endocrine remission. The 2-, 4-, and 6-year actuarial remission rates were 54%, 78%, and 87%, respectively. New-onset neurological deficit was found in 4 (6.3%) patients following treatment. New-onset hypopituitarism was observed in 27 (43.5%) patients, with panhypopituitarism in 2 (3.2%). Higher margin/maximum dose were significantly associated with a higher remission rate and development of post-SRS hypopituitarism.
CONCLUSION:
Whole-sellar SRS for invasive or imaging-negative FPA following failed resection can offer reasonable rates of endocrine remission. Hypopituitarism following whole-sellar SRS is the most common complication.
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Affiliation(s)
- Cheng-Chia Lee
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Chun-Po Yen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- Department of Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
| | - Francis Fezeu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- Department of Radiation Oncology, University of Virginia Health System, Charlottesville, Virginia
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