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Corsello A, Paragliola RM, Salvatori R. Diagnosing and treating the elderly individual with hypopituitarism. Rev Endocr Metab Disord 2024; 25:575-597. [PMID: 38150092 DOI: 10.1007/s11154-023-09870-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/18/2023] [Indexed: 12/28/2023]
Abstract
Hypopituitarism in the elderly is an underestimated condition mainly due to the non-specific presentation that can be attributed to the effects of aging and the presence of comorbidities. Diagnosis and treatment of hypopituitarism often represent a challenging task and this is even more significant in the elderly. Diagnosis can be insidious due to the physiological changes occurring with aging that complicate the interpretation of hormonal investigations, and the need to avoid some provocative tests that carry higher risks of side effects in this population. Treatment of hypopituitarism has generally the goal to replace the hormonal deficiencies to restore a physiological balance as close as possible to that of healthy individuals but in the elderly this must be balanced with the risks of over-replacement and worsening of comorbidities. Moreover, the benefit of some hormonal replacement therapies in the elderly, including sex hormones and growth hormone, remains controversial.
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Affiliation(s)
- Andrea Corsello
- Unità di Chirurgia Endocrina, Ospedale Isola Tiberina - Gemelli Isola, 00186, Rome, Italy
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168, Rome, Italy
| | - Rosa Maria Paragliola
- Unicamillus-Saint Camillus International University of Health Sciences, 00131, Rome, Italy
| | - Roberto Salvatori
- Division of Endocrinology, Department of Medicine, and Pituitary Center, Johns Hopkins University, Baltimore, MD, 2187, USA.
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2
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Balen AH, Tamblyn J, Skorupskaite K, Munro MG. A comprehensive review of the new FIGO classification of ovulatory disorders. Hum Reprod Update 2024; 30:355-382. [PMID: 38412452 DOI: 10.1093/humupd/dmae003] [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: 06/12/2023] [Revised: 01/23/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND The World Health Organization (WHO) system for the classification of disorders of ovulation was produced 50 years ago and, by international consensus, has been updated by the International Federation of Gynecology and Obstetrics (FIGO). OBJECTIVE AND RATIONALE This review outlines in detail each component of the FIGO HyPO-P (hypothalamic, pituitary, ovarian, PCOS) classification with a concise description of each cause, and thereby provides a systematic method for diagnosis and management. SEARCH METHODS We searched the published articles in the PubMed database in the English-language literature until October 2022, containing the keywords ovulatory disorders; ovulatory dysfunction; anovulation, and each subheading in the FIGO HyPO-P classification. We did not include abstracts or conference proceedings because the data are usually difficult to assess. OUTCOMES We present the most comprehensive review of all disorders of ovulation, published systematically according to the logical FIGO classification. WIDER IMPLICATIONS Improving the diagnosis of an individual's ovulatory dysfunction will significantly impact clinical practice by enabling healthcare practitioners to make a precise diagnosis and plan appropriate management.
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Affiliation(s)
- Adam H Balen
- Leeds Centre for Reproductive Medicine, The University of Leeds, Leeds, UK
| | - Jennifer Tamblyn
- Leeds Centre for Reproductive Medicine, The University of Leeds, Leeds, UK
| | | | - Malcolm G Munro
- Department of Obstetrics and Gynecology, The University of California, Los Angeles, Los Angeles, CA, USA
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3
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Ryder CY, Bellile EL, VanKoevering KK, McKean EL. Assessing Quality of Life among Radiation-Induced Hypopituitary Patients. J Neurol Surg B Skull Base 2023; 84:567-577. [PMID: 37854537 PMCID: PMC10581824 DOI: 10.1055/a-1934-9377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 08/29/2022] [Indexed: 10/14/2022] Open
Abstract
Introduction Radiation-induced hypopituitarism (RIH) has long been recognized as one of the deleterious side effects of skull base radiation. This study aims to assess the quality of life (QoL) among patients with RIH compared with radiated patients who did not develop hypopituitarism using the validated Anterior Skull Base Questionnaire (ASBQ). Methods This was a single-institution retrospective cohort study. Included patients had a history of anterior skull base tumor, underwent at least one round of radiation to the skull base, and had filled out at least one ASBQ survey after their radiation treatment. Three statistical models were used to determine the effect of hypopituitarism and treatment on QoL scores. Results A total of 145 patients met inclusion criteria, and 330 ASBQ surveys were analyzed. Thirty-five percent (51/145) had evidence of RIH at some point after their radiation treatment. Those with hypopituitarism had significantly lower overall ASBQ scores across all three models even after adjusting for potential confounders and intraperson correlation (average decrease of 0.24-0.45 on a 5-point Likert scale; p -values ranging from 0.0004 to 0.018). The increase in QoL with hormonal replacement was modulated by time out from radiation, with long-term survivors (5+ years out from radiation) gaining the most benefit from treatment (increase of 0.89 on a 5-point Likert scale, p 0.0412), especially in the vitality domain. Conclusion This data demonstrates that hypopituitarism is an independent predictor of lower QoL. Early detection and appropriate treatment are essential to avoid the negative impact of hypopituitarism on QoL.
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Affiliation(s)
- C Yoonhee Ryder
- University of Michigan Medical School, Office of Medical Student Education, Ann Arbor, Michigan, United States
| | - Emily L. Bellile
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, United States
| | - Kyle K. VanKoevering
- Department of Otolaryngology, Ohio State University, Columbus, Ohio, United States
| | - Erin L. McKean
- Department of Otolaryngology Head and Neck Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States
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4
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Szulc-Lerch K, Yeung J, de Guzman AE, Egan S, Yee Y, Fernandes D, Lerch JP, Mabbott DJ, Nieman BJ. Exercise promotes growth and rescues volume deficits in the hippocampus after cranial radiation in young mice. NMR IN BIOMEDICINE 2023; 36:e5015. [PMID: 37548099 DOI: 10.1002/nbm.5015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 08/08/2023]
Abstract
Human and animal studies suggest that exercise promotes healthy brain development and function, including promoting hippocampal growth. Childhood cancer survivors that have received cranial radiotherapy exhibit hippocampal volume deficits and are at risk of impaired cognitive function, thus they may benefit from regular exercise. While morphological changes induced by exercise have been characterized using magnetic resonance imaging (MRI) in humans and animal models, evaluation of changes across the brain through development and following cranial radiation is lacking. In this study, we used high-resolution longitudinal MRI through development to evaluate the effects of exercise in a pediatric mouse model of cranial radiation. Female mice received whole-brain radiation (7 Gy) or sham radiation (0 Gy) at an infant equivalent age (P16). One week after irradiation, mice were housed in either a regular cage or a cage equipped with a running wheel. In vivo MRI was performed prior to irradiation, and at three subsequent timepoints to evaluate the effects of radiation and exercise. We used a linear mixed-effects model to assess volumetric and cortical thickness changes. Exercise caused substantial increases in the volumes of certain brain regions, notably the hippocampus in both irradiated and nonirradiated mice. Volume increases exceeded the deficits induced by cranial irradiation. The effect of exercise and irradiation on subregional hippocampal volumes was also characterized. In addition, we characterized cortical thickness changes across development and found that it peaked between P23 and P43, depending on the region. Exercise also induced regional alterations in cortical thickness after 3 weeks of voluntary exercise, while irradiation did not substantially alter cortical thickness. Our results show that exercise has the potential to alter neuroanatomical outcomes in both irradiated and nonirradiated mice. This supports ongoing research exploring exercise as a strategy for improving neurocognitive development for children, particularly those treated with cranial radiotherapy.
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Affiliation(s)
- Kamila Szulc-Lerch
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, Canada
| | - Jonas Yeung
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, Canada
- Translational Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - A Elizabeth de Guzman
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, Canada
- Translational Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
- Functional Neuroimaging Laboratory, Istituto Italiano di Tecnologia, Rovereto, Italy
| | - Shannon Egan
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, Canada
- Translational Medicine, Hospital for Sick Children, Toronto, Canada
| | - Yohan Yee
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
- Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Canada
| | - Darren Fernandes
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
- Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Canada
| | - Jason P Lerch
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
- Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Canada
- Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Donald J Mabbott
- Neuroscience and Mental Health, Hospital for Sick Children, Toronto, Canada
- Department of Psychology, Hospital for Sick Children, Toronto, Canada
| | - Brian J Nieman
- Mouse Imaging Centre, Hospital for Sick Children, Toronto, Canada
- Translational Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
- Ontario Institute for Cancer Research, Toronto, Canada
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5
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Xie P, Hu H, Cao X, Lan N, Zhang H, Yan R, Yue P, Hu W, Qiao H. Frequency of metastases within the hypothalamic-pituitary area and the associated high-risk factors in patients with brain metastases. Front Neurol 2023; 14:1285662. [PMID: 38099066 PMCID: PMC10720031 DOI: 10.3389/fneur.2023.1285662] [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: 08/30/2023] [Accepted: 11/13/2023] [Indexed: 12/17/2023] Open
Abstract
Objective Brain radiotherapy often results in impairment of hypothalamic-pituitary (HT-P) function, which in turn causes secretory dysfunction of related hormones. In this paper, the frequency of metastasis in the HT-P area and its high-risk factors in patients with brain metastasis were retrospectively analyzed, and thus provide experimental evidence for protecting HT-P area during whole brain radiotherapy (WBRT). Methods A retrospective analysis was performed on the data of patients with brain metastasis diagnosed by cranial magnetic resonance imaging (MRI) at the First Hospital of Lanzhou University from 2017 to 2020. The anatomical positions of the hypothalamus and pituitary were delineated, followed by their expansion by 5 mm outwards, respectively, in the three-dimensional direction, and the hypothalamus +5 mm and pituitary +5 mm were obtained as the avoidance area, in which the frequency of brain metastasis was evaluated. Univariate and multivariate logistic regression models were used to analyze the high risk factors of brain metastasis in HT-P area. Results A total of 3,375 brain metastatic lesions from 411 patients were included in the analysis. The rates of brain metastasis in the hypothalamus +5 mm and pituitary +5 mm in the whole group of cases were 2.9% (12/411) and 1.5% (6/411) respectively; the frequency of lesions was 0.4% (13/3375) and 0.2% (6/3375) respectively. Univariate and multivariate analyses showed that the number of brain metastases (OR = 14.946; 95% CI = 4.071-54.880; p < 0.001), and the occurrence of brain metastasis in the pituitary (OR = 13.331; 95% CI = 1.511-117.620; p = 0.020) were related to brain metastasis in the hypothalamus, and that the only relevant factor for brain metastasis in the pituitary was the occurrence of that in the hypothalamus (OR = 0.069; 95% CI = 0.010-0.461; p = 0.006). There was no correlation between tumor pathological types, the maximum diameter, the total volume of brain metastatic lesions and the risk of brain metastasis in hypothalamus and pituitary. Conclusion The frequency of brain metastasis in the HT-P area is extremely low. The risk of brain metastases in the hypothalamus is correlated with their number. The larger the number of metastatic lesions, the higher the frequency of brain metastasis. Protection of the HT-P area during WBRT may be unlikely to compromise the tumor recurrence rate for patients with a relatively small number of brain metastases.
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Affiliation(s)
- Peng Xie
- Department of Radiation Oncology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Huiling Hu
- CT Room, The First People’s Hospital of Lanzhou City, Lanzhou, China
| | - Xiong Cao
- Department of Thoracic Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Ning Lan
- Department of Radiotherapy, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Huanyu Zhang
- Department of Radiation Oncology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Ruifeng Yan
- Department of Radiology, The First Hospital of Lanzhou University, Lanzhou, China
| | - Peng Yue
- Department of Thoracic Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Wenteng Hu
- Department of Thoracic Surgery, The First Hospital of Lanzhou University, Lanzhou, China
| | - Hui Qiao
- Department of Oncology, The First Hospital of Lanzhou University, Lanzhou, China
- School of Life Sciences, Lanzhou University, Lanzhou, China
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Mercantepe F, Tumkaya L, Mercantepe T, Rakici SY, Ciftel S, Ciftel S. Radioprotective effects of α2-adrenergic receptor agonist dexmedetomidine on X-ray irradiation-induced pancreatic islet cell damage. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:1827-1836. [PMID: 36877270 DOI: 10.1007/s00210-023-02454-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
Comprehensive epidemiological analyses conducted in the last 30 years have revealed a link between radiation and DM. We aimed to determine the effects of dexmedetomidine pretreatment on radiation-induced pancreatic islet cell damage. Twenty-four rats were divided into three groups: group 1 (control group), group 2 (only X-ray irradiation group), and group 3 (X-ray irradiation + dexmedetomidine). We observed necrotic cells with vacuoles accompanying loss of cytoplasm in the islets of Langerhans, extensive edematous areas, and vascular congestions in group 2. In group 3, we observed a decrease in necrotic cells in the islets of Langerhans, and edematous areas and vascular congestion was also reduced. We determined a decrease in β-cells, α-cells, and D-cells in the islets of Langerhans in group 2 compared to the control group. In group 3, β-cells, α-cells, and D-cells were elevated compared to group 2. Ionizing radiation may induce DM. Dexmedetomidine appears to exert a radioprotective effect.
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Affiliation(s)
- Filiz Mercantepe
- Department of Endocrinology and Metabolism, Faculty of Medicine, Recep Tayyip Erdogan University, 2 Nolu Sehitler Street, Rize, 53020, Turkey.
| | - Levent Tumkaya
- Department of Histology and Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Tolga Mercantepe
- Department of Histology and Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Sema Yilmaz Rakici
- Department of Radiation Oncology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Serpil Ciftel
- Department of Endocrinology and Metabolism, Faculty of Medicine, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
| | - Sedat Ciftel
- Department of Gastroenterology, Faculty of Medicine, Erzurum Regional Education and Research Hospital, Erzurum, Turkey
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Shaaban SG, LeCompte MC, Kleinberg LR, Redmond KJ, Page BR. Recognition and Management of the Long-term Effects of Cranial Radiation. Curr Treat Options Oncol 2023; 24:880-891. [PMID: 37145381 DOI: 10.1007/s11864-023-01078-z] [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] [Accepted: 03/08/2023] [Indexed: 05/06/2023]
Abstract
OPINION STATEMENT Cranial radiation is ubiquitous in the treatment of primary malignant and benign brain tumors as well as brain metastases. Improvement in radiotherapy targeting and delivery has led to prolongation of survival outcomes. As long-term survivorship improves, we also focus on prevention of permanent side effects of radiation and mitigating the impact when they do occur. Such chronic treatment-related morbidity is a major concern with significant negative impact on patient's and caregiver's respective quality of life. The actual mechanisms responsible for radiation-induced brain injury remain incompletely understood. Multiple interventions have been introduced to potentially prevent, minimize, or reverse the cognitive deterioration. Hippocampal-sparing intensity modulated radiotherapy and memantine represent effective interventions to avoid damage to regions of adult neurogenesis. Radiation necrosis frequently develops in the high radiation dose region encompassing the tumor and surrounding normal tissue. The radiographic findings in addition to the clinical course of the patients' symptoms are taken into consideration to differentiate between tissue necrosis and tumor recurrence. Radiation-induced neuroendocrine dysfunction becomes more pronounced when the hypothalamo-pituitary (HP) axis is included in the radiation treatment field. Baseline and post-treatment evaluation of hormonal profile is warranted. Radiation-induced injury of the cataract and optic system can develop when these structures receive an amount of radiation that exceeds their tolerance. Special attention should always be paid to avoid irradiation of these sensitive structures, if possible, or minimize their dose to the lowest limit.
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Affiliation(s)
- Sherif G Shaaban
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins Medicine, 401 North Broadway, Suite 1440, Baltimore, MD, 21287, USA
| | - Michael C LeCompte
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins Medicine, 401 North Broadway, Suite 1440, Baltimore, MD, 21287, USA
| | - Lawrence R Kleinberg
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins Medicine, 401 North Broadway, Suite 1440, Baltimore, MD, 21287, USA
| | - Kristin J Redmond
- Department of Radiation Oncology & Molecular Radiation Sciences, Johns Hopkins Medicine, 401 North Broadway, Suite 1440, Baltimore, MD, 21287, USA
| | - Brandi R Page
- Department of Radiation Oncology-National Capitol Region, Johns Hopkins Medicine, 6420 Rockledge Drive Suite 1200, Bethesda, MD, 20817, USA.
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Mercantepe F, Tumkaya L, Mercantepe T, Rakici S. Histopathological evaluation of the effects of dexmedetomidine against pituitary damage ınduced by X-ray irradiation. Biomarkers 2023; 28:168-176. [PMID: 36453587 DOI: 10.1080/1354750x.2022.2154385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background: The present study, aimed to investigate the potential negative effects of x-ray radiation and the effects of the α2-adrenergic receptor agonist dexmedetomidine on the pituitary gland.Methods: Twenty-four Sprague-Dawley rats were divided into three groups: Rats in Group 1 (control group). Group 2 (X-ray irradiation) and group 3 (X-ray irradiation + Dexmedetomidine) were given a total of 10 Gy external beam total body irradiation. Group 3 was given a single intraperitoneal dose of 200 µg/kg dexmedetomidine 30 minutes before RT.Results: In sections obtained from the x-ray irradiation group, we observed many necrotic in adenohypophysis and neurohypophysis. In addition, there were extensive oedematous areas and vascular congestions due to the necrotic cells in both the adenohypophysis and neurohypophysis. In contrast, we observed a reduction in necrotic chromophobic and chromophilic cells in adenohypophyseal tissue and a reduction in necrotic pituicytes in neurohypophyseal tissue in the dexmedetomidine treatment group. In addition, we determined lower caspase-3 and TUNEL expression in the dexmedetomidine treatment group compared with the x-ray irradiation group. Dexmedetomidine reduced x-ray radiation-induced pituitary damage by preventing apoptosis.Conclusions: The present study demonstrated the use of dexmedetomidine in situations related to radiation toxicity and offers the potential for a comprehensive study.
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Affiliation(s)
- Filiz Mercantepe
- Department of Endocrinology and Metabolism Diseases, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Levent Tumkaya
- Department of Histology and Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Tolga Mercantepe
- Department of Histology and Embryology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Sema Rakici
- Department of Radiation Oncology, Faculty of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
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Zhai R, Lyu Y, Ni M, Kong F, Du C, Hu C, Ying H. Predictors of radiation-induced hypothyroidism in nasopharyngeal carcinoma survivors after intensity-modulated radiotherapy. Radiat Oncol 2022; 17:57. [PMID: 35313921 PMCID: PMC8935811 DOI: 10.1186/s13014-022-02028-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 03/09/2022] [Indexed: 11/13/2022] Open
Abstract
Background The aim of the study is to identify clinical and dosimetric factors that could predict the risk of hypothyroidism in nasopharyngeal carcinoma (NPC) patients following intensity-modulated radiotherapy (IMRT). Methods A total of 404 non-metastatic NPC patients were included in our study. All patients were treated with IMRT. The thyroid function were performed for all patients before and after radiation at regular intervals. The time onset for developing hypothyroidism was defined as the time interval between the completion of RT and the first recorded abnormal thyroid hormone test. The cumulative incidence rates of hypothyroidism were estimated using Kaplan–Meier method. Univariate and multivariate Cox regression analyses were performed to detect the most promising factors that were associated with hypothyroidism. Results Median follow up was 60.6 months. The 3-, 5- and 7- year cumulative incidence rate of hypothyroidism was 39.4%, 49.1% and 54.7%, respectively. The median time to primary hypothyroidism and central hypothyroidism were 15.4 months (range 2.9–83.8 months) and 29.9 months (range 19.8–93.6 months), respectively. Univariate and multivariate analyses revealed that younger age, female gender and small thyroid volume were the most important factors in predicting the risk of hypothyroidism. Dtmean (mean dose of thyroid), V30-V50 (percentage of thyroid volume receiving a certain dose level) and VS45-VS60 (the absolute volumes of thyroid spared from various dose levels) remained statistically significant in multivariate analyses. Cutoff points of 45 Gy (Dtmean), 80% (Vt40) and 5 cm3 (VS45Gy) were identified to classify patients as high-risk or low-risk group. Conclusion Thyroid Vt40 highly predicted the risk of hypothyroidism after IMRT for NPC patients. We recommended plan optimization objectives to reduce thyroid Vt40 to 80%. Trial registration: Retrospectively registered.
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Affiliation(s)
- Ruiping Zhai
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Room 703, Building 1, Dong'an Road 270, Shanghai, 200032, China
| | - Yingchen Lyu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Room 703, Building 1, Dong'an Road 270, Shanghai, 200032, China
| | - Mengshan Ni
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Room 703, Building 1, Dong'an Road 270, Shanghai, 200032, China
| | - Fangfang Kong
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Room 703, Building 1, Dong'an Road 270, Shanghai, 200032, China
| | - Chengrun Du
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Room 703, Building 1, Dong'an Road 270, Shanghai, 200032, China
| | - Chaosu Hu
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Room 703, Building 1, Dong'an Road 270, Shanghai, 200032, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Hongmei Ying
- Department of Radiation Oncology, Fudan University Shanghai Cancer Center, Room 703, Building 1, Dong'an Road 270, Shanghai, 200032, China. .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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10
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Multi-Planar VMAT Plans for High-Grade Glioma and Glioblastoma Targeting the Hypothalamic-Pituitary Axis Sparing. Life (Basel) 2022; 12:life12020195. [PMID: 35207484 PMCID: PMC8880591 DOI: 10.3390/life12020195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/31/2021] [Accepted: 01/19/2022] [Indexed: 12/21/2022] Open
Abstract
Background: This study aimed to identify the better arc configuration of volumetric modulated arc therapy (VMAT) for high-grade glioma and glioblastoma, focusing on a dose reduction to the hypothalamic–pituitary axis through an analysis of dose-volumetric parameters, as well as a correlation analysis between the planned target volume (PTV) to organs at risk (OAR) distance and the radiation dose. Method: Twenty-four patients with 9 high-grade glioma and 15 glioblastomas were included in this study. Identical CT, MRI and structure sets of each patient were used for coplanar VMAT (CO-VMAT), dual planar VMAT (DP-VMAT) and multi-planar VMAT (MP-VMAT) planning. The dose constraints adhered to the RTOG0825 and RTOG9006 protocols. The dose-volumetric parameters of each plan were collected for statistical analysis. Correlation analyses were performed between radiation dose and PTV-OARs distance. Results: The DP-VMAT and MP-VMAT achieved a significant dose reduction to most nearby OARs when compared to CO-VMAT, without compromising the dose to PTV, plan homogeneity and conformity. For centrally located OARs, including the hypothalamus, pituitary, brain stem and optic chiasm, the dose reductions ranged from 2.65 Gy to 3.91 Gy (p < 0.001) in DP-VMAT and from 2.57 Gy to 4 Gy (p < 0.001) in MP-VMAT. Similar dose reduction effects were achieved for contralaterally located OARs, including the hippocampus, optic nerve, lens and retina, ranging from 1.06 Gy to 4.37 Gy in DP-VMAT and from 0.54 Gy to 3.39 Gy in MP-VMAT. For ipsilaterally located OARs, DP-VMAT achieved a significant dose reduction of 1.75 Gy to Dmax for the optic nerve. In the correlation analysis, DP-VMAT and MP-VMAT showed significant dose reductions to centrally located OARs when the PTV-OAR distance was less than 4 cm. In particular, DP-VMAT offered better sparing to the optic chiasm when it was located less than 2 cm from the PTV than that of MP-VMAT and CO-VMAT. DP-VMAT and MP-VMAT also showed better sparing to the contralateral hippocampus and retina when they were located 3–8 cm from the PTV. Conclusion: The proposed DP-VMAT and MP-VMAT demonstrated significant dose reductions to centrally located and contralateral OARs and maintained the high plan qualities to PTV with good homogeneity and conformity when compared to CO-VMAT for high-grade glioma and glioblastoma. The benefit in choosing DP-VMAT and MP-VMAT over CO-VMAT was substantial when the PTV was located near the hypothalamus, pituitary, optic chiasm, contralateral hippocampus and contralateral retina.
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11
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Modern LINAC-based radiotherapy is safe and effective in the treatment of secretory and non-secretory pituitary adenomas. World Neurosurg 2021; 160:e33-e39. [PMID: 34971832 DOI: 10.1016/j.wneu.2021.12.087] [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: 11/01/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Adjuvant radiotherapy (RT) can help achieve local tumor control (LC) and reduce hormonal overexpression for pituitary adenomas (PAs). Prior reports involved Gamma Knife or older LINAC techniques. We report on long-term outcomes for modern LINAC RT. METHODS Institutional retrospective review of LINAC RT for PAs with minimum 3 years MRI follow-up. Hormonal control defined as biochemical remission in absence of medications targeting hormone excess LC defined using RECIST on surveillance MRIs. Progression Free Survival (PFS) defined as time alive with LC and without return of or worsening hormonal excess from secretory PA. Kaplan-Meier method and Cox proportional hazard models used. RESULTS From 2003-2017, 140 patients with PAs (94 non-secretory, 46 secretory) were treated with LINAC RT (105 fractionated, 35 radiosurgery) with mFU of 5.35 years. Techniques included fixed gantry IMRT (51.4%), DCA (9.3%), and VMAT (39.3%). PFS at 5-years was 95.3% for secretory tumors and 94.8% for non-secretory tumors. Worse PFS associated with larger PTV on MVA (HR 2.87, 95% CI 1.01 - 8.21, p=0.049). Hormonal control at 5 years was 50.0% and associated with higher dose to the tumor (HR 1.05, 95% CI 1.02 -1.09, p=0.005) and number of surgeries (HR 1.74, 95% CI 1.05-2.89, p=0.032). Patients requiring any pituitary hormone replacement increased from 57.9% to 70.0% after radiotherapy. CONCLUSION Modern LINAC RT for patients with PAs was safe and effective for hormonal control and LC. Notably, no difference in LC was noted for functional versus non-functional tumors possibly due to higher total dose and daily image guidance.
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12
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Stress Axis in the Cancer Patient: Clinical Aspects and Management. ENDOCRINES 2021. [DOI: 10.3390/endocrines2040044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hypothalamus–pituitary–adrenal (HPA) axis alterations are common in cancer patients, mainly due to the different antitumoral therapies, which lead to several acute and late endocrine side effects. This review summarizes the most recent evidence regarding HPA derangement, both in patients with active neoplasms and in cancer survivors, with particular attention to the impact of the different antitumoral treatments, focusing on the major clinical aspects. While acute hormone failure usually results from injury caused directly by tumor burden or surgical interventions, short- and long-term effects are generally due to chemotherapy, radiotherapy and, as more recently shown, to different types of targeted- and immuno-therapy. Adrenal insufficiency (AI) is mostly caused by pituitary or hypothalamic injury rather than a direct damage of the adrenal gland. Moreover, other treatments commonly employed as supportive therapy or in the context of palliative care (i.e., glucocorticoids, opioids) can lead to HPA dysfunction. Epidemiology and pathophysiology of stress axis alterations in cancer patients still require clarification. Since AI may represent a life-threatening condition, monitoring adrenal function in cancer patients is mandatory, especially in subjects who experience fatigue or during stress conditions, in order to promptly start replacement treatment when needed.
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Ayoub R, Lau K, Yuen N, Fernandes D, Elder M, Yeung J, Wong SC, Nieman BJ. Spatiotemporal Mapping of Early Volume Loss in the Mouse Brain after Cranial Irradiation. Radiat Res 2021; 196:394-403. [PMID: 34270782 DOI: 10.1667/rade-21-00013.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/05/2021] [Indexed: 11/03/2022]
Abstract
Sequelae after pediatric cranial radiotherapy (CRT) result in long-term changes in brain structure. While past evidence indicates regional differences in brain volume change, it remains unclear how these manifest in the time course of change after CRT. In this study, we spatiotemporally characterized volume losses induced by cranial irradiation in a mouse model, with a dense sampling of measurements over the first week postirradiation. Wild-type mice received whole-brain irradiation (7 Gy) or sham irradiation (0 Gy) at 16 days of age. In vivo magnetic resonance imaging was performed at one time point before, and 2-4 time points postirradiation in each mouse, with a particular focus on sampling during the first week after cranial irradiation. Volume changes across the brain were measured, and the degree and timing of volume loss were quantified across structures from a predefined atlas. Volume measurements across the brain after cranial irradiation revealed a ∼2-day delay in which volume is not significantly altered, after which time volume change proceeds over the course of four days. Volume losses were 3% larger and emerged 40% slower in white matter than in gray matter. Large volume loss was also observed in the ventricles. Differences in the timing and magnitude of volume change between gray and white matter after cranial irradiation were observed. These results suggest differences in the mechanism and/or kinetics underlying the associated radio-response, which may have implications in development.
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Affiliation(s)
- Ramy Ayoub
- Departments of Medical Biophysics, University of Toronto, Ontario, Canada
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kaylie Lau
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nili Yuen
- Departments of Medical Biophysics, University of Toronto, Ontario, Canada
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Darren Fernandes
- Departments of Medical Biophysics, University of Toronto, Ontario, Canada
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Madeline Elder
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jonas Yeung
- Departments of Medical Biophysics, University of Toronto, Ontario, Canada
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shun C Wong
- Departments of Medical Biophysics, University of Toronto, Ontario, Canada
- Departments of Radiation Oncology, University of Toronto, Ontario, Canada
- Institute of Medical Science, University of Toronto, Ontario, Canada
- The Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Brian J Nieman
- Departments of Medical Biophysics, University of Toronto, Ontario, Canada
- Mouse Imaging Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
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14
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Liu X, Dai C, Feng M, Li M, Chen G, Wang R. Diagnosis and treatment of refractory pituitary adenomas: a narrative review. Gland Surg 2021; 10:1499-1507. [PMID: 33968701 DOI: 10.21037/gs-20-873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although aggressive pituitary adenomas (PAs) have been proposed and widely discussed for more than a decade, there is no general agreement regarding their definition, diagnosis or management. As one of the largest pituitary centers in China, we have diagnosed and treated more than fifty cases of aggressive PA and 3 pituitary carcinomas in the past 5 years and proposed a new term, i.e., refractory PAs, to define these adenomas. The definitions of aggressive and refractory PAs overlap with each other, though there are some differences between them. We interpret the definition for refractory PA in this review, emphasizing that more attention and early identification of these adenomas are needed. Although temozolomide (TMZ) has been used to treat pituitary carcinomas and refractory PA since 2006, which has significantly improved the prognosis of these patients, treatment of refractory PA is a tremendous challenge for endocrinologists and neurosurgeons. Overall, refractory PA is defined as PA with a Ki-67 labeling index ≥3%, a faster growth rate than that of normal PA, infiltration of surrounding tissues, recurrence or regrowth in the early postoperative period, and continued growth and/or secretion of excessive hormones despite attempts to control it. These criteria for refractory PA are stricter than for aggressive PA. The diagnosis and treatment of refractory PA requires the collaboration of a multidisciplinary team to achieve the best results.
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Affiliation(s)
- Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Congxin Dai
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Tongren Hospital Capital Medical University, Beijing, China
| | - Ming Feng
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingchu Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Ge Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Renzhi Wang
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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15
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Ferraù F, Ceccato F, Cannavò S, Scaroni C. What we have to know about corticosteroids use during Sars-Cov-2 infection. J Endocrinol Invest 2021; 44:693-701. [PMID: 32860209 PMCID: PMC7454136 DOI: 10.1007/s40618-020-01384-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/02/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Glucocorticoids (GCs), alone or associated to other drugs, were widely used in the management of patients affected by severe acute respiratory syndrome caused by SARS-CoV-2 infection, during the recent COVID-19 outbreak. This review summarizes the available data on HPA axis impairment in GC-treated SARS-CoV-2 patients, focusing on the risk of adrenal insufficiency and on potential drug interactions during concomitant treatments. METHODS Literature on the impact of GCs therapy on HPA axis and on the consequences of coadministration of GCs and other drugs in SARS-CoV-2 patients has been reviewed. RESULTS GC treatment can cause symptoms of hypercortisolism, especially in patients with individual hypersensibility, or hypoadrenalism after drug withdrawal, due to hypothalamic-pituitary-adrenal (HPA) axis suppression, with consequences in terms of increased morbidity and mortality risk. On the other hand, in SARS-CoV-2-infected patient's cortisol secretion could be insufficient also due to critical illness-related corticosteroid insufficiency (CIRCI). In addition, in this clinical context, the co-administration of antiretroviral drugs and corticosteroids may trigger drug-drug interaction and enhance the exposure to the latter ones, metabolized through the CYP450 CYP3A pathway, severely impacting on HPA axis. CONCLUSION Physicians involved in the management of patients affected by COVID-19 should be aware of the need of an appropriate GC dose tapering, and of potential interaction of GCs with antiviral therapy and drugs used to treat associated co-morbidities.
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Affiliation(s)
- F Ferraù
- Department of Human Pathology of Adulthood and Childhood 'G. Barresi', AOU Policlinico Gaetano Martino, UOC di Endocrinologia, University of Messina, Pad. H, 4° piano, Via Consolare Valeria, 1, 98125, Messina, Italy.
- Endocrine Unit, University Hospital G. Martino, Messina, Italy.
| | - F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
| | - S Cannavò
- Department of Human Pathology of Adulthood and Childhood 'G. Barresi', AOU Policlinico Gaetano Martino, UOC di Endocrinologia, University of Messina, Pad. H, 4° piano, Via Consolare Valeria, 1, 98125, Messina, Italy
- Endocrine Unit, University Hospital G. Martino, Messina, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
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16
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Ceccato F, Barbot M, Lizzul L, Cuccarollo A, Selmin E, Merante Boschin I, Daniele A, Saller A, Occhi G, Regazzo D, Scaroni C. Clinical presentation and management of acromegaly in elderly patients. Hormones (Athens) 2021; 20:143-150. [PMID: 32840821 PMCID: PMC7889670 DOI: 10.1007/s42000-020-00235-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/30/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND AIM Acromegaly is a rare disease with a peak of incidence in early adulthood. However, enhanced awareness of this disease, combined with wide availability of magnetic resonance imaging (MRI), has increased the diagnosis of forms with mild presentation, especially in elderly patients. Moreover, due to increased life expectancy and proactive individualized treatment, patients with early-onset acromegaly are today aging. The aim of our study was to describe our cohort of elderly patients with acromegaly. MATERIALS AND METHODS This is a cross-sectional retrospective study of 96 outpatients. Clinical, endocrine, treatment, and follow-up data were collected using the electronic database of the University Hospital of Padova, Italy. RESULTS We diagnosed acromegaly in 13 patients, aged ≥65 years, presenting with relatively small adenomas and low IGF-1 secretion. Among them, 11 patients were initially treated with medical therapy and half normalized hormonal levels after 6 months without undergoing neurosurgery (TNS). Remission was achieved after TNS in three out of four patients (primary TNS in two); ten patients presented controlled acromegaly at the last visit. Acromegaly-related comorbidities (colon polyps, thyroid cancer, adrenal incidentaloma, hypertension, and bone disease) were more prevalent in patients who had an early diagnosis (31 patients, characterized by a longer follow-up of 24 years) than in those diagnosed aged ≥65 years (5 years of follow-up). CONCLUSIONS Elderly acromegalic patients are not uncommon. Primary medical therapy is a reasonable option and is effectively used, while the rate of surgical success is not reduced. A careful cost-benefit balance is suggested. Disease-specific comorbidities are more prevalent in acromegalic patients with a longer follow-up rather than in those diagnosed aged ≥65 years.
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Affiliation(s)
- Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Via Ospedale Civile, 105-35128, Padova, Italy.
- Department of Neurosciences DNS, University of Padova, Padova, Italy.
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
| | - Laura Lizzul
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
| | - Angela Cuccarollo
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
| | - Elisa Selmin
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
| | - Isabella Merante Boschin
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
- Department of Surgical, Oncological and Gastroenterological Sciences DiSCOG, University of Padova, Padova, Italy
| | - Andrea Daniele
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
| | - Alois Saller
- Internal Medicine, Department of Medicine DIMED, University Hospital of Padova, Padova, Italy
| | - Gianluca Occhi
- Department of Biology, University of Padova, Padova, Italy
| | - Daniela Regazzo
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University Hospital of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
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Sharma MB, Jensen K, Amidi A, Eskildsen SF, Johansen J, Grau C. Late toxicity in the brain after radiotherapy for sinonasal cancer: Neurocognitive functioning, MRI of the brain and quality of life. Clin Transl Radiat Oncol 2020; 25:52-60. [PMID: 33024844 PMCID: PMC7530204 DOI: 10.1016/j.ctro.2020.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/31/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022] Open
Abstract
Compared with matched normative data, impaired cognitive function was substantial. Several correlations between radiation dose and cognitive impairment were present. Radiation-induced white matter hyperintensities were present in 2/27 participants. One participant displayed radiation-induced necrosis in the temporal lobe. The domains affecting quality of life the most were fatigue and quality of sleep.
Purpose The aim of the study was to evaluate neurocognitive late effects, structural alterations and associations between cognitive impairment and radiation doses as well as cerebral tissue damage after radiotherapy for sinonasal cancer. Furthermore, the aim was to report quality of life (QoL) and self-reported cognitive capacity. Materials and methods Recurrence-free patients previously treated with intensity-modulated radiotherapy with a curative intent were eligible for the study. Study examinations comprised comprehensive neurocognitive testing, MRI of the brain, and self-reported outcomes. Results A total of 27 patients were included. Median age was 67 years (range 47–83). The majority of test outcomes were below normative values in any degree, and 37% of the participants had clinically significant neurocognitive impairment when compared with normative data. Correlations between absorbed doses to specific substructures of the brain and neurocognitive outcomes were present for Wechsler’s Adult Intelligence Scale-digit span and Controlled Oral Word Association Test-S. Structural MRI revealed macroscopic abnormalities in three patients; infarction (n = 1), diffuse white matter intensities (n = 2) and necrosis (n = 1). In the analysis of atrophy of cerebral tissue, no correlations were present with neither radiation dose to cerebral substructures nor neurocognitive impairment. The global QoL of the cohort was 75. The most affected outcomes were ‘fatigue’, ‘insomnia’, and ‘drowsiness’. A total of 59% of participants reported significantly impaired quality of sleep. Self-reported cognitive function revealed that ‘memory’ was the most affected cognitive domain. For the domains of ‘memory’ and ‘language’, self-reported functioning was associated with objectively measured neurocognitive outcomes. Conclusion Cerebral toxicity after radiotherapy for sinonasal cancer was substantial. Clinically significant cognitive impairment was present in more than one third of the participants, and several dose–response associations were present. Furthermore, the presence of macroscopic radiation sequelae indicated considerable impact of radiotherapy on brain tissue.
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Affiliation(s)
- M B Sharma
- Department of Oncology, Aarhus University Hospital, Palle Juul Jensen Boulevard 99, DK-8200 Aarhus N, Denmark
| | - K Jensen
- Danish Center for Particle Therapy, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, B420, 8200 Aarhus N, Denmark
| | - A Amidi
- Unit for Psychooncology and Health Psychology, Department of Psychology, Aarhus University, Bartholins Allé 9, Build. 1351, 8000 Aarhus C, Denmark
| | - S F Eskildsen
- Center of Functionally Integrative Neuroscience, Aarhus University, Nørrebrogade 44, Build. 1A, 8000 Aarhus C, Denmark
| | - J Johansen
- Department of Oncology, Odense University Hospital, J.B. Winsløvs Vej 4, 5000 Odense, Denmark
| | - C Grau
- Department of Oncology, Aarhus University Hospital, Palle Juul Jensen Boulevard 99, DK-8200 Aarhus N, Denmark.,Danish Center for Particle Therapy, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, B420, 8200 Aarhus N, Denmark
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18
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Sharma MB, Jensen K, Urbak SF, Funding M, Johansen J, Bechtold D, Amidi A, Eskildsen SF, Jørgensen JOL, Grau C. A multidimensional cohort study of late toxicity after intensity modulated radiotherapy for sinonasal cancer. Radiother Oncol 2020; 151:58-65. [PMID: 32697945 DOI: 10.1016/j.radonc.2020.07.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/12/2020] [Accepted: 07/15/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE To evaluate the occurrence of late toxicity after curatively intended intensity modulated radiotherapy (IMRT) for sinonasal cancer and assess dose-response associations. METHODS Patients treated with IMRT in 2008-2016 were included. Cross sectional examinations of toxicity from the optic pathway, the brain, the pituitary gland and the nose were performed along with quality of life - (QoL) and dose-response analyses. RESULTS Twenty-seven patients were enrolled; median age was 67 years (range 47-83). Five patients (19%) had radiation-related ocular toxicity. The risk of visual acuity impairment increased with increasing dose (grade 2 odds ration (OR) 1.12, p = 0.01; grade 3 OR 1.14, p = 0.02) and dose constraint violations (grade 2, OR = 21, p < 0.01; grade 3, OR = 41, p < 0.01). Six patients (22%) exhibited evidence of radiation-related hypopituitarism, but no dose-response association was detected. Seventeen patients (63%) had impaired olfactory function. The risk of olfactory impairment increased with higher stage (OR = 3.32, p = 0.03). Three patients (11%) had structural abnormalities in irradiated areas of the brain, and impaired cognitive function was present in 17 patients (63%). Cognitive, physical, role functioning as well as fatigue and insomnia were affected the most in QOL analyses. Fifteen patients (56%) had grade 2 radiation-related impairment in at least one organ. Grade 3 toxicity was only present in patients with toxicities in >3 organs and in patients initially treated for T4 tumours. Three patients (11%) had radiation-related impaired function in all examined OARs. CONCLUSION Late toxicity after radiotherapy was substantial in all examined organs, with dose-response associations between visual acuity impairment and the optic nerve. The results have led to changed praxis for follow-up examinations in Denmark.
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Affiliation(s)
| | - Kenneth Jensen
- Danish Center for Particle Therapy, Aarhus University Hospital, Denmark
| | - Steen Fiil Urbak
- Department of Ophthalmology, Aarhus University Hospital, Denmark
| | - Mikkel Funding
- Department of Ophthalmology, Aarhus University Hospital, Denmark
| | | | - Dorte Bechtold
- Department of Ophthalmology, Odense University Hospital, Denmark
| | - Ali Amidi
- Unit for Psychooncology and Health Psychology, Department of Psychology, Aarhus University, Denmark
| | | | | | - Cai Grau
- Department of Oncology, Aarhus University Hospital, Denmark; Danish Center for Particle Therapy, Aarhus University Hospital, Denmark
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Mehta P, Janssen S, Fahlbusch FB, Schmid SM, Gebauer J, Cremers F, Ziemann C, Tartz M, Rades D. Sparing the hippocampus and the hypothalamic- pituitary region during whole brain radiotherapy: a volumetric modulated arc therapy planning study. BMC Cancer 2020; 20:610. [PMID: 32605648 PMCID: PMC7325372 DOI: 10.1186/s12885-020-07091-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Feasibility testing of a simultaneous sparing approach of hippocampus, hypothalamus and pituitary gland in patients undergoing whole-brain radiotherapy (WBRT) with and without a concomitant boost to metastatic sites. INTRODUCTION Cognitive impairment and hormonal dysfunction are common side effects of cranial radiotherapy. A reduced dose application to the patho-physiologically involved functional brain areas, i.e. hippocampus, hypothalamus and pituitary gland, could reduce these common side effects. While hippocampal sparing is already a common practice to improve cognitive outcome, technical experience of additional combined sparing of the hypothalamus/pituitary gland (HT-P) is insufficient. METHODS Twenty patients were included in the planning study. In 11 patients, a total dose of 36 Gy of WBRT (2 Gy per fraction) plus a simultaneous integrated boost (SIB) of 9 Gy (0.5 Gy per fraction, total dose: 45 Gy) to the brain metastases was applied. In 9 patients, prophylactic cranial irradiation (PCI) was simulated with a total dose of 30 Gy (2 Gy per fraction). In both patient cohorts, a sparing approach of the hippocampus and the HT-P area was simulated during WBRT. For all treatment plans, volumetric modulated arc therapy (VMAT) was used. Quality assurance included assessment of homogeneity, conformality and target coverage. RESULTS The mean dose to the hippocampus and HT-P region was limited to less than 50% of the prescribed dose to the planning target volume (PTV) in all treatment plans. Dose homogeneity (HI) of the target volume was satisfying (median HI = 0.16 for WBRT+SIB and 0.1 for PCI) and target coverage (conformation number, CN) was not compromised (median CN = 0.82 for SIB and 0.86 for PCI). CONCLUSION Simultaneous dose reduction to the hippocampus and the HT-P area did not compromise the PTV coverage in patients undergoing WBRT+SIB or PCI using VMAT. While the feasibility of the presented approach is promising, prospective neurologic, endocrine outcome and safety studies are required.
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Affiliation(s)
- P Mehta
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - S Janssen
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany.
- Private Practice of Radiation Oncology, Hannover, Germany.
| | - F B Fahlbusch
- Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander-University of Erlangen-Nürnberg, Erlangen, Germany
| | - S M Schmid
- Institute for Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - J Gebauer
- Institute for Endocrinology and Diabetes, University of Lübeck, Lübeck, Germany
| | - F Cremers
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - C Ziemann
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
| | - M Tartz
- Private Practice of Radiation Oncology, Hannover, Germany
| | - D Rades
- Department of Radiation Oncology, University of Lübeck, Lübeck, Germany
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20
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Assessing the association of tumor consistency and gland manipulation on hormonal outcomes and delayed hyponatremia in pituitary macroadenoma surgery. INTERDISCIPLINARY NEUROSURGERY-ADVANCED TECHNIQUES AND CASE MANAGEMENT 2020. [DOI: 10.1016/j.inat.2019.100628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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21
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Mendel JT, Jaster AW, Yu FF, Morris LC, Lynch PT, Shah BR, Agarwal A, Timmerman RD, Nedzi LA, Raj KM. Fundamentals of Radiation Oncology for Neurologic Imaging. Radiographics 2020; 40:827-858. [PMID: 32216705 DOI: 10.1148/rg.2020190138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Although the physical and biologic principles of radiation therapy have remained relatively unchanged, a technologic renaissance has led to continuous and ever-changing growth in the field of radiation oncology. As a result, medical devices, techniques, and indications have changed considerably during the past 20-30 years. For example, advances in CT and MRI have revolutionized the treatment planning process for a variety of central nervous system diseases, including primary and metastatic tumors, vascular malformations, and inflammatory diseases. The resultant improved ability to delineate normal from abnormal tissue has enabled radiation oncologists to achieve more precise targeting and helped to mitigate treatment-related complications. Nevertheless, posttreatment complications still occur and can pose a diagnostic challenge for radiologists. These complications can be divided into acute, early-delayed, and late-delayed complications on the basis of the time that they manifest after radiation therapy and include leukoencephalopathy, vascular complications, and secondary neoplasms. The different irradiation technologies and applications of these technologies in the brain, current concepts used in treatment planning, and essential roles of the radiation oncologist in the setting of brain disease are reviewed. In addition, relevant imaging findings that can be used to delineate the extent of disease before treatment, and the expected posttreatment imaging changes are described. Common and uncommon complications related to radiation therapy and the associated imaging manifestations also are discussed. Familiarity with these entities may aid the radiologist in making the diagnosis and help guide appropriate management. ©RSNA, 2020.
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Affiliation(s)
- J Travis Mendel
- From the Departments of Radiation Oncology (J.T.M., P.T.L., R.D.T., L.A.N.) and Radiology (A.W.J., F.F.Y., L.C.M., B.R.S., A.A., K.M.R.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Adam W Jaster
- From the Departments of Radiation Oncology (J.T.M., P.T.L., R.D.T., L.A.N.) and Radiology (A.W.J., F.F.Y., L.C.M., B.R.S., A.A., K.M.R.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Fang F Yu
- From the Departments of Radiation Oncology (J.T.M., P.T.L., R.D.T., L.A.N.) and Radiology (A.W.J., F.F.Y., L.C.M., B.R.S., A.A., K.M.R.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Lee C Morris
- From the Departments of Radiation Oncology (J.T.M., P.T.L., R.D.T., L.A.N.) and Radiology (A.W.J., F.F.Y., L.C.M., B.R.S., A.A., K.M.R.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Patrick T Lynch
- From the Departments of Radiation Oncology (J.T.M., P.T.L., R.D.T., L.A.N.) and Radiology (A.W.J., F.F.Y., L.C.M., B.R.S., A.A., K.M.R.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Bhavya R Shah
- From the Departments of Radiation Oncology (J.T.M., P.T.L., R.D.T., L.A.N.) and Radiology (A.W.J., F.F.Y., L.C.M., B.R.S., A.A., K.M.R.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Amit Agarwal
- From the Departments of Radiation Oncology (J.T.M., P.T.L., R.D.T., L.A.N.) and Radiology (A.W.J., F.F.Y., L.C.M., B.R.S., A.A., K.M.R.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Robert D Timmerman
- From the Departments of Radiation Oncology (J.T.M., P.T.L., R.D.T., L.A.N.) and Radiology (A.W.J., F.F.Y., L.C.M., B.R.S., A.A., K.M.R.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Lucien A Nedzi
- From the Departments of Radiation Oncology (J.T.M., P.T.L., R.D.T., L.A.N.) and Radiology (A.W.J., F.F.Y., L.C.M., B.R.S., A.A., K.M.R.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
| | - Karuna M Raj
- From the Departments of Radiation Oncology (J.T.M., P.T.L., R.D.T., L.A.N.) and Radiology (A.W.J., F.F.Y., L.C.M., B.R.S., A.A., K.M.R.), The University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390
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VanKoevering KK, Sabetsarvestani K, Sullivan SE, Barkan A, Mierzwa M, McKean EL. Pituitary Dysfunction after Radiation for Anterior Skull Base Malignancies: Incidence and Screening. J Neurol Surg B Skull Base 2020; 81:75-81. [PMID: 32021753 DOI: 10.1055/s-0039-1679893] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/30/2018] [Indexed: 12/19/2022] Open
Abstract
Background Management of anterior cranial base malignancies requires multidisciplinary care. Radiation therapy remains a mainstay of definitive or adjuvant treatment. Apart from primary hypothyroidism, the effects of radiation on the hypothalamic-pituitary axis after high-dose treatment of head and neck malignancies remain poorly described. We describe a comprehensive screening protocol for surveillance and characterize the incidence of pituitary dysfunction after radiation for anterior cranial base malignancies. Methods A review of patients prospectively enrolled in a skull base registry at an academic center was performed. Included patients had a history of anterior skull base malignancy and external beam radiation to the primary site, with comprehensive post-treatment pituitary serologies and at least 1 year of post-radiation follow-up. Routine hormonal screening was initiated during the study period for all patients with anterior skull base irradiation. Results Eighty-one patients met inclusion. Fifty-eight patients (71%) demonstrated some laboratory abnormality. Thirty patients (37%) demonstrated evidence of hypopituitarism. Twenty-four (29%) demonstrated central hypogonadism, and 16% of patients showed central hypothyroidism. Ten patients (12%) displayed central adrenal insufficiency with six patients demonstrating panhypopituitarism. Primary tumor location and maximum dose of radiation to the gland appeared to correlate with incidence of hypopituitarism. Conclusion Radiation for malignancies of the anterior skull base resulted in a 37% incidence of hypopituitarism in our study. Given the potential morbidity of hypopituitarism, we recommend annual post-treatment screening in these patients. We describe a comprehensive set of serologies that can be utilized, and recommend updating clinical guidelines to reflect the necessity of this screening.
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Affiliation(s)
- Kyle K VanKoevering
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, United States
| | | | - Stephen E Sullivan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Ariel Barkan
- Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Michelle Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan, United States
| | - Erin L McKean
- Department of Otolaryngology, Head and Neck Surgery, University of Michigan, Ann Arbor, Michigan, United States.,Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
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23
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Ceccato F, Scaroni C. Central adrenal insufficiency: open issues regarding diagnosis and glucocorticoid treatment. ACTA ACUST UNITED AC 2019; 57:1125-1135. [DOI: 10.1515/cclm-2018-0824] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/13/2018] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Central adrenal insufficiency (CAI) is characterized by impaired adrenocorticotropin (ACTH) secretion because of a disease or injury to the hypothalamus or the pituitary, leading to a reduced cortisol production. CAI suspicion arises more frequently in patients with pituitary tumors, cranial irradiation/surgery/injury/infections, as well as after exogenous glucocorticoid withdrawal. Nevertheless, a late diagnosis is not uncommon because CAI may present with nonspecific signs or symptoms, as fatigue or hyponatremia.
Content
The PubMed database was searched (years 1980–2018), using “central adrenal insufficiency” and “ACTH deficiency” as keywords. Subsequently, reference sections of the retrieved articles were searched.
Summary
Dynamic tests are needed when morning basal cortisol levels are not sufficient to exclude or to confirm CAI. Short Synacthen Test (SST) is the most used, and Endocrine Society’s guidelines recommend a cortisol peak >500 nmol/L to exclude CAI. Despite thresholds, understanding the pretest probability of ACTH deficiency (the clinical background of the patient) is essential because the diagnostic accuracy of SST in case of a negative result is suboptimal. Glucocorticoid replacement therapy, able to replicate cortisol circadian rhythm, is required in patients with CAI; fludrocortisone treatment is not necessary. Short-acting glucocorticoid drugs (hydrocortisone or cortisone acetate) are the most used; lower doses than previously used are nowadays recommended to reduce cortisol-related comorbidities. Promising results have been obtained with modified-release hydrocortisone, especially regarding glucose metabolism in patients with primary adrenal insufficiency.
Outlook
An accurate clinical diagnosis and a careful individualized therapy are mandatory in patients with CAI.
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25
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Lamba N, Bussiere MR, Niemierko A, Abedi P, Fullerton BC, Loeffler JS, Oh KS, Nachtigall LB, Shih HA. Hypopituitarism After Cranial Irradiation for Meningiomas: A Single-Institution Experience. Pract Radiat Oncol 2019; 9:e266-e273. [DOI: 10.1016/j.prro.2019.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 01/25/2019] [Accepted: 01/27/2019] [Indexed: 02/06/2023]
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26
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Simultaneously avoiding the hippocampus and hypothalamic-pituitary axis during whole brain radiotherapy: A planning study. Med Dosim 2019; 44:130-135. [DOI: 10.1016/j.meddos.2018.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/08/2018] [Accepted: 04/09/2018] [Indexed: 01/19/2023]
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27
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Vatner RE, Niemierko A, Misra M, Weyman EA, Goebel CP, Ebb DH, Jones RM, Huang MS, Mahajan A, Grosshans DR, Paulino AC, Stanley T, MacDonald SM, Tarbell NJ, Yock TI. Endocrine Deficiency As a Function of Radiation Dose to the Hypothalamus and Pituitary in Pediatric and Young Adult Patients With Brain Tumors. J Clin Oncol 2018; 36:2854-2862. [PMID: 30118397 DOI: 10.1200/jco.2018.78.1492] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There are sparse data defining the dose response of radiation therapy (RT) to the hypothalamus and pituitary in pediatric and young adult patients with brain tumors. We examined the correlation between RT dose to these structures and development of endocrine dysfunction in this population. MATERIALS AND METHODS Dosimetric and clinical data were collected from children and young adults (< 26 years of age) with brain tumors treated with proton RT on three prospective studies (2003 to 2016). Deficiencies of growth hormone (GH), thyroid hormone, adrenocorticotropic hormone, and gonadotropins were determined clinically and serologically. Incidence of deficiency was estimated using the Kaplan-Meier method. Multivariate models were constructed accounting for radiation dose and age. RESULTS Of 222 patients in the study, 189 were evaluable by actuarial analysis, with a median follow-up of 4.4 years (range, 0.1 to 13.3 years), with 31 patients (14%) excluded from actuarial analysis for having baseline hormone deficiency and two patients (0.9%) because of lack of follow-up. One hundred thirty patients (68.8%) with medulloblastoma were treated with craniospinal irradiation (CSI) and boost; most of the remaining patients (n = 56) received involved field RT, most commonly for ependymoma (13.8%; n = 26) and low-grade glioma (7.4%; n = 14). The 4-year actuarial rate of any hormone deficiency, growth hormone, thyroid hormone, adrenocorticotropic hormone, and gonadotropin deficiencies were 48.8%, 37.4%, 20.5%, 6.9%, and 4.1%, respectively. Age at start of RT, time interval since treatment, and median dose to the combined hypothalamus and pituitary were correlated with increased incidence of deficiency. CONCLUSION Median hypothalamic and pituitary radiation dose, younger age, and longer follow-up time were associated with increased rates of endocrinopathy in children and young adults treated with radiotherapy for brain tumors.
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Affiliation(s)
- Ralph E Vatner
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Andrzej Niemierko
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Madhusmita Misra
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Elizabeth A Weyman
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Claire P Goebel
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - David H Ebb
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Robin M Jones
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Mary S Huang
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Anita Mahajan
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - David R Grosshans
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Arnold C Paulino
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Takara Stanley
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Shannon M MacDonald
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Nancy J Tarbell
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
| | - Torunn I Yock
- Ralph E. Vatner, Andrzej Niemierko, Madhusmita Misra, Elizabeth A. Weyman, Claire P. Goebel, David H. Ebb, Robin M. Jones, Mary S. Huang, Takara Stanley, Shannon M. MacDonald, Nancy J. Tarbell, and Torunn I. Yock, Massachusetts General Hospital, Boston, MA; Ralph E. Vatner, University of Cincinnati College of Medicine and Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Anita Mahajan, Mayo Clinic, Rochester, MN; and David R. Grosshans and Arnold C. Paulino, MD Anderson Cancer Center, Houston, TX
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Inskip PD, Veiga LH, Brenner AV, Sigurdson AJ, Ostroumova E, Chow EJ, Stovall M, Smith SA, Weathers RE, Leisenring W, Robison LL, Armstrong GT, Sklar CA, Lubin JH. Hypothyroidism after Radiation Therapy for Childhood Cancer: A Report from the Childhood Cancer Survivor Study. Radiat Res 2018; 190:117-132. [PMID: 29763379 PMCID: PMC6161838 DOI: 10.1667/rr14888.1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
While thyroid cancer risks from exposure to ionizing radiation early in life are well characterized quantitatively, the association of radiation with nonmalignant, functional thyroid disorders has been less studied. Here, we report on a risk analysis study of hypothyroidism with radiation dose to the thyroid gland and the hypothalamic-pituitary axis among survivors of childhood cancer. Utilizing data from the Childhood Cancer Survivor Study, a cohort of 14,364 five-year survivors of childhood cancer diagnosed at 26 hospitals in the U.S. and Canada between 1970 and 1986 and followed through 2009, the occurrence of hypothyroidism was ascertained among 12,015 survivors through serial questionnaires. Radiation doses to the thyroid gland and pituitary gland were estimated from radiotherapy records. Binary outcome regression was used to estimate prevalence odds ratios for hypothyroidism at five years from diagnosis of childhood cancer and Poisson regression to model incidence rate ratios (RR) after the first five years. A total of 1,193 cases of hypothyroidism were observed, 777 (65%) of which occurred five or more years after cancer diagnosis. The cumulative proportion affected with hypothyroidism (prevalence at five years after cancer diagnosis plus incidence through 30 years after cancer diagnosis) was highest among five-year survivors of Hodgkin lymphoma (32.3%; 95% CI: 29.5-34.9) and cancers of the central nervous system (17.7%; 95% CI: 15.2-20.4). The incidence rate was significantly associated with radiation dose to the thyroid and pituitary. The joint association of hypothyroidism with thyroid and pituitary dose was sub-additive for pituitary doses greater than 16 Gy. In particular, a very strong thyroid radiation dose dependence at low-to-moderate pituitary/hypothalamic doses was diminished at high pituitary doses. Radiation-related risks were higher in males than females and inversely associated with age at exposure and time since exposure but remained elevated more than 25 years after exposure. Our findings indicated that hypothyroidism was significantly associated with treatment with bleomycin (RR = 3.4; 95% CI: 1.6-7.3) and the alkylating agents cyclohexyl-chloroethyl-nitrosourea (CCNU) (RR = 3.0; 95% CI: 1.5-5.3) and cyclophosphamide (RR = 1.3; 95% CI: 1.0-1.8), with a significant dose response for CCNU ( P < 0.01). The risk of hypothyroidism among childhood cancer survivors treated with radiation depends both on direct, dose-dependent radiation-induced damage to the thyroid gland and on dose-dependent indirect effects secondary to irradiation of the hypothalamic-pituitary axis. The dose-response relationship for each site depends on dose to the other. Radiation-related risk persists for more than 25 years after treatment. Treatment with certain chemotherapy agents may increase the risk of hypothyroidism.
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Affiliation(s)
- Peter D. Inskip
- Radiation Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD,
USA
- Retired
| | - Lene H.S. Veiga
- Radiation Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD,
USA
- Institute for Radiation Protection and Dosimetry, Brazilian
Nuclear Energy Commission, Rio de Janeiro, Brazil
| | - Alina V. Brenner
- Radiation Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD,
USA
| | - Alice J. Sigurdson
- Radiation Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD,
USA
- Retired
| | - Evgenia Ostroumova
- Radiation Epidemiology Branch, Division of Cancer
Epidemiology and Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD,
USA
- International Agency for Research on Cancer, Lyon,
France
| | - Eric J. Chow
- Clinical Research and Public Health Sciences Divisions,
Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Marilyn Stovall
- Department of Radiation Physics, The University of Texas MD
Anderson Cancer Center; Houston, TX, USA
- Retired
| | - Susan A. Smith
- Department of Radiation Physics, The University of Texas MD
Anderson Cancer Center; Houston, TX, USA
| | - Rita E. Weathers
- Department of Radiation Physics, The University of Texas MD
Anderson Cancer Center; Houston, TX, USA
| | - Wendy Leisenring
- Clinical Research and Public Health Sciences Divisions,
Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude
Children’s Research Hospital; Memphis, TN, USA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude
Children’s Research Hospital; Memphis, TN, USA
| | - Charles A. Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer
Center, New York, NY, USA
| | - Jay H. Lubin
- Biostatistics Branch, Division of Cancer Epidemiology and
Genetics, National Cancer Institute, NIH, DHHS, Bethesda, MD, USA
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Visual Outcomes and Local Control After Fractionated Stereotactic Radiotherapy for Optic Nerve Sheath Meningioma. Ophthalmic Plast Reconstr Surg 2018; 34:217-221. [PMID: 28422769 DOI: 10.1097/iop.0000000000000914] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE To review the outcomes of patients with optic nerve sheath meningiomas (ONSM) treated with fractionated stereotactic radiotherapy. METHODS Patient characteristics, treatment, and outcomes were analyzed for all patients with primary and secondary ONSM treated from 2001 to 2012. Clinically significant visual acuity change was defined as a 2-line change on the Snellen eye chart from pre-fractionated stereotactic radiotherapy. RESULTS Forty-one patients were treated: 23 patients with primary ONSM and 18 patients with secondary ONSM. The median age at diagnosis was 56 years. The median visual follow up was 3.8 years and the median radiologic follow up was 4.4 years. At diagnosis, 36% had normal vision (20/20-20/40), 10% had mild impairment (<20/40-20/60), 20% had moderate visual impairment (<20/60-20/200), 27% had severe impairment (<20/200), and 7% had no light perception. Common acute side effects were headache (32%) and nausea (15%); 15% of patients required corticosteroids during stereotactic radiotherapy. Chronic toxicities included retinopathy (7%), pituitary dysfunction (13%), chronic ocular pain (5%), and cataracts (2%). Visual acuity was stable in 65%, improved in 27%, and decreased in 8% of patients. Visual fields were stable in 70%, improved in 21%, and reduced in 9%. Actuarial 5-year local control rates were 100% for primary ONSM and 88% for secondary ONSM. Actuarial 5-year visual preservation rates were 100% for primary ONSM and 86% for secondary ONSM. CONCLUSIONS Fractionated stereotactic radiotherapy for primary and secondary ONSM was well tolerated and provides excellent local control and visual preservation. Longer follow up is required to determine the risk of late ocular and pituitary sequelae.
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Doknić M, Pekić S, Miljić D, Soldatović I, Popović V, Stojanović M, Petakov M. Etiology of Hypopituitarism in Adult Patients: The Experience of a Single Center Database in the Serbian Population. Int J Endocrinol 2017; 2017:6969286. [PMID: 28702053 PMCID: PMC5494080 DOI: 10.1155/2017/6969286] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 03/27/2017] [Indexed: 11/26/2022] Open
Abstract
There are only a few published studies related to the population-based etiology of hypopituitarism. New risks for developing hypopituitarism have been recognized in the last 10 years. Aim. To present data regarding the etiology of hypopituitarism collected in a tertiary center over the last decade. This is a cross-sectional database study. Patients and Methods. We included 512 patients (pts) with hypopituitarism, with a mean age of 45.9 ± 1.7 yrs (range: 18-82; male: 57.9%). Results. Nonfunctional pituitary adenomas were presented in 205 pts (40.5%), congenital causes in 74 pts (14.6%), while acromegaly and prolactinomas were presented in 37 (7.2%) and 36 (7.0%) patients, respectively. Craniopharyngiomas were detected in 30 pts (5.9%), and head trauma due to trauma brain injury-TBI and subarachnoid hemorrhage-SAH in 27 pts (5.4%). Survivors of hemorrhagic fever with renal syndrome (HFRS) and those with previous cranial irradiation were presented in the same frequency (18 pts, 3.5% each). Conclusion. The most common causes of hypopituitarism in our database are pituitary adenomas. Increased awareness of the other causes of pituitary dysfunction, such as congenital, head trauma, extrapituitary cranial irradiation, and infections, is the reason for a higher frequency of these etiologies of hypopituitarism in the presented database.
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Affiliation(s)
- M. Doknić
- Neuroendocrine Department, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- *M. Doknić:
| | - S. Pekić
- Neuroendocrine Department, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - D. Miljić
- Neuroendocrine Department, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - I. Soldatović
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Institute of Medical Statistics and Informatics, Belgrade, Serbia
| | - V. Popović
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - M. Stojanović
- Neuroendocrine Department, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - M. Petakov
- Neuroendocrine Department, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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Felicetti F, Fortunati N, Arvat E, Brignardello E. GH deficiency in adult survivors of childhood cancer. Best Pract Res Clin Endocrinol Metab 2016; 30:795-804. [PMID: 27974192 DOI: 10.1016/j.beem.2016.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Childhood cancer survivors (CCS) are a fast growing population, but late adverse effects of cancer therapies are not rare. In CCS treated with cranial radiotherapy, growth hormone deficiency (GHD) is a well-known occurrence and the potential impact of GH replacement therapy on the global outcome of CCS is under continuous evaluation. In the present review, we discuss advantages and disadvantages of GH replacement therapy in survivors of pediatric malignancies, taking into consideration the different reasons for treating GHD during childhood or adult life. It is doubtless that GH treatment is advisable to obtain a normal growth in pediatric patients. As far as the beginning/continuation of the replacement therapy in adult age is concerned, contrasting results have been reported in literature. The suggestion is that the decision to treat adult CCS should be taken after careful evaluation of each patient's clinical history and of the potential side effects, in agreement with the patients.
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Affiliation(s)
- Francesco Felicetti
- Transition Unit for Childhood Cancer Survivors, Department of Oncology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126, Turin, Italy.
| | - Nicoletta Fortunati
- Transition Unit for Childhood Cancer Survivors, Department of Oncology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126, Turin, Italy; Oncological Endocrinology Unit, Department of Oncology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126, Turin, Italy.
| | - Emanuela Arvat
- Oncological Endocrinology Unit, Department of Oncology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126, Turin, Italy; Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Turin, Italy.
| | - Enrico Brignardello
- Transition Unit for Childhood Cancer Survivors, Department of Oncology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126, Turin, Italy.
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Complicaciones endocrinas precoces en supervivientes de neoplasias infantiles. Med Clin (Barc) 2016; 147:329-333. [DOI: 10.1016/j.medcli.2016.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 11/21/2022]
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Noël G, Antoni D, Barillot I, Chauvet B. Délinéation des organes à risque et contraintes dosimétriques. Cancer Radiother 2016; 20 Suppl:S36-60. [DOI: 10.1016/j.canrad.2016.07.032] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abreu A, Tovar AP, Castellanos R, Valenzuela A, Giraldo CMG, Pinedo AC, Guerrero DP, Barrera CAB, Franco HI, Ribeiro-Oliveira A, Vilar L, Jallad RS, Duarte FG, Gadelha M, Boguszewski CL, Abucham J, Naves LA, Musolino NRC, de Faria MEJ, Rossato C, Bronstein MD. Challenges in the diagnosis and management of acromegaly: a focus on comorbidities. Pituitary 2016; 19:448-57. [PMID: 27279011 PMCID: PMC4935749 DOI: 10.1007/s11102-016-0725-2] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Acromegaly is a rare, insidious disease resulting from the overproduction of growth hormone (GH) and insulin-like growth factor 1 (IGF-1), and is associated with a range of comorbidities. The extent of associated complications and mortality risk is related to length of exposure to the excess GH and IGF-1, thus early diagnosis and treatment is imperative. Unfortunately, acromegaly is often diagnosed late, when patients already have a wide range of comorbidities. The presence of comorbid conditions contributes significantly to patient morbidity/mortality and impaired quality of life. METHODS We conducted a retrospective literature review for information relating to the diagnosis of acromegaly, and its associated comorbidities using PubMed. The main aim of this review is to highlight the issues of comorbidities in acromegaly, and to reinforce the importance of early diagnosis and treatment. FINDINGS AND CONCLUSIONS Successful management of acromegaly goes beyond treating the disease itself, since many patients are diagnosed late in disease evolution, they present with a range of comorbid conditions, such as cardiovascular disease, diabetes, hypertension, and sleep apnea. It is important that patients are screened carefully at diagnosis (and thereafter), for common associated complications, and that biochemical control does not become the only treatment goal. Mortality and morbidities in acromegaly can be reduced successfully if patients are treated using a multimodal approach with comprehensive comorbidity management.
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Affiliation(s)
- Alin Abreu
- Endocrinology Unit, Centro Médico Imbanaco Cali, Cali, Colombia
| | - Alejandro Pinzón Tovar
- Internal Medicine Department, Hospital of Neiva, University Surcolombiana, Neiva, Colombia
| | - Rafael Castellanos
- Internal Medicine Department, University Industrial of Santander, Bucaramanga, Colombia
| | - Alex Valenzuela
- Department of Internal Medicine, Endocrinology Fundación Cardio-Infantil, Instituto de Cardiología, Universidad del Rosario, Bogotá, Colombia
| | | | | | - Doly Pantoja Guerrero
- Endocrinology Unit, Hospital Universitario Departamental de Nariño, CENTRO de Endocrinologia CENDOO, Universidad Nacional de Colombia, Pasto, Colombia
| | - Carlos Alfonso Builes Barrera
- Endocrinology Department, Hospital Universitario San Vicente Fundación, Universidad de Antioquia, Medellín, Colombia
| | | | | | - Lucio Vilar
- Endocrinology and Chair, Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University Medical School, Recife, Brazil
| | - Raquel S Jallad
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, Av. Dr. Eneas de Carvalho, 255, 7ºandar, sala 7037, São Carlos, SP, CEP 05403-000, Brazil
| | - Felipe Gaia Duarte
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, Av. Dr. Eneas de Carvalho, 255, 7ºandar, sala 7037, São Carlos, SP, CEP 05403-000, Brazil
| | - Mônica Gadelha
- Endocrine Section, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cesar Luiz Boguszewski
- Department of Internal Medicine, Endocrine Division (SEMPR), Federal University of Paraná, Curitiba, Brazil
| | - Julio Abucham
- Neuroendocrine Unit, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Luciana A Naves
- Department of Endocrinology, Faculty of Medicine, University of Brasilia, Brasília, Brazil
| | - Nina Rosa C Musolino
- Neuroendocrine Unit, Division of Neurosurgery, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, SP, Brazil
| | - Maria Estela Justamante de Faria
- Department of Odontology, Central Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, SP, Brazil
| | - Ciliana Rossato
- Department of Odontology, Central Unit, Hospital das Clínicas, University of Sao Paulo School of Medicine, São Paulo, SP, Brazil
| | - Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, Av. Dr. Eneas de Carvalho, 255, 7ºandar, sala 7037, São Carlos, SP, CEP 05403-000, Brazil.
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Radiation-Induced Growth Retardation and Microstructural and Metabolite Abnormalities in the Hippocampus. Neural Plast 2016; 2016:3259621. [PMID: 27242931 PMCID: PMC4875992 DOI: 10.1155/2016/3259621] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 02/11/2016] [Accepted: 04/05/2016] [Indexed: 11/17/2022] Open
Abstract
Cranial radiotherapy (CRT) increases survival in pediatric brain-tumor patients but can cause deleterious effects. This study evaluates the acute and long-term impact of CRT delivered during childhood/adolescence on the brain and body using a rodent model. Rats received CRT, either 4 Gy fractions × 5 d (fractionated) or a cumulative dose of 20 Gy (single dose) at 28 d of age. Animals were euthanized 1 d, 5 d, or 3.5 mo after CRT. The 3.5 mo group was imaged prior to euthanasia. At 3.5 mo, we observed significant growth retardation in irradiated animals, versus controls, and the effects of single dose on brain and body weights were more severe than fractionated. Acutely single dose significantly reduced body weight but increased brain weight, whereas fractionation significantly reduced brain but not body weights, versus controls. CRT suppressed cell proliferation in the hippocampal subgranular zone acutely. Fractional anisotropy (FA) in the fimbria was significantly lower in the single dose versus controls. Hippocampal metabolite levels were significantly altered in the single dose animals, reflecting a heightened state of inflammation that was absent in the fractionated. Our findings indicate that despite the differences in severity between the doses they both demonstrated an effect on cell proliferation and growth retardation, important factors in pediatric CRT.
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Mörén L, Wibom C, Bergström P, Johansson M, Antti H, Bergenheim AT. Characterization of the serum metabolome following radiation treatment in patients with high-grade gliomas. Radiat Oncol 2016; 11:51. [PMID: 27039175 PMCID: PMC4818859 DOI: 10.1186/s13014-016-0626-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 03/22/2016] [Indexed: 11/26/2022] Open
Abstract
Background Glioblastomas progress rapidly making response evaluation using MRI insufficient since treatment effects are not detectable until months after initiation of treatment. Thus, there is a strong need for supplementary biomarkers that could provide reliable and early assessment of treatment efficacy. Analysis of alterations in the metabolome may be a source for identification of new biomarker patterns harboring predictive information. Ideally, the biomarkers should be found within an easily accessible compartment such as the blood. Method Using gas-chromatographic- time-of-flight-mass spectroscopy we have analyzed serum samples from 11 patients with glioblastoma during the initial phase of radiotherapy. Fasting serum samples were collected at admittance, on the same day as, but before first treatment and in the morning after the second and fifth dose of radiation. The acquired data was analyzed and evaluated by chemometrics based bioinformatics methods. Our findings were compared and discussed in relation to previous data from microdialysis in tumor tissue, i.e. the extracellular compartment, from the same patients. Results We found a significant change in metabolite pattern in serum comparing samples taken before radiotherapy to samples taken during early radiotherapy. In all, 68 metabolites were lowered in concentration following treatment while 16 metabolites were elevated in concentration. All detected and identified amino acids and fatty acids together with myo-inositol, creatinine, and urea were among the metabolites that decreased in concentration during treatment, while citric acid was among the metabolites that increased in concentration. Furthermore, when comparing results from the serum analysis with findings in tumor extracellular fluid we found a common change in metabolite patterns in both compartments on an individual patient level. On an individual metabolite level similar changes in ornithine, tyrosine and urea were detected. However, in serum, glutamine and glutamate were lowered after treatment while being elevated in the tumor extracellular fluid. Conclusion Cross-validated multivariate statistical models verified that the serum metabolome was significantly changed in relation to radiation in a similar pattern to earlier findings in tumor tissue. However, all individual changes in tissue did not translate into changes in serum. Our study indicates that serum metabolomics could be of value to investigate as a potential marker for assessing early response to radiotherapy in malignant glioma. Electronic supplementary material The online version of this article (doi:10.1186/s13014-016-0626-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lina Mörén
- Department of Chemistry, Computational Life Science Cluster, Umeå University, SE 901 87, Umeå, Sweden. .,Department of Chemistry, Umeå University, SE 90187, Umeå, Sweden.
| | - Carl Wibom
- Department of Radiation Sciences, Oncology, Umeå University, SE 901 85, Umeå, Sweden
| | - Per Bergström
- Department of Radiation Sciences, Oncology, Umeå University, SE 901 85, Umeå, Sweden
| | - Mikael Johansson
- Department of Radiation Sciences, Oncology, Umeå University, SE 901 85, Umeå, Sweden
| | - Henrik Antti
- Department of Chemistry, Computational Life Science Cluster, Umeå University, SE 901 87, Umeå, Sweden
| | - A Tommy Bergenheim
- Department of Clinical Neuroscience, Neurosurgery, Umeå University, SE 901 85, Umeå, Sweden
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Tallen G, Resch A, Calaminus G, Wiener A, Leiss U, Pletschko T, Friedrich C, Langer T, Grabow D, Driever PH, Kortmann RD, Timmermann B, Pietsch T, Warmuth-Metz M, Bison B, Thomale UW, Krauss J, Mynarek M, von Hoff K, Ottensmeier H, Frühwald M, Kramm CM, Temming P, Müller HL, Witt O, Kordes U, Fleischhack G, Gnekow A, Rutkowski S. Strategies to improve the quality of survival for childhood brain tumour survivors. Eur J Paediatr Neurol 2015; 19:619-39. [PMID: 26278499 DOI: 10.1016/j.ejpn.2015.07.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 07/05/2015] [Indexed: 01/01/2023]
Abstract
BACKGROUND Tumours of the central nervous system (CNS) are the most frequent solid tumours and the second most frequent type of cancer in children and adolescents. Overall survival has continuously improved in Germany, since an increasing number of patients have been treated according to standardised, multicentre, multimodal treatment recommendations, trials of the German Paediatric Brain Tumour Consortium (HIT-Network) or the International Society of Paediatric Oncology-Europe (SIOP-E) during the last decades. Today, two out of three patients survive. At least 8000 long-term childhood brain tumour survivors (CBTS) are currently living in Germany. They face lifelong disease- and treatment-related late effects (LE) and associated socioeconomic problems more than many other childhood cancer survivors (CCS). METHOD We review the LE and resulting special needs of this particular group of CCS. RESULTS Despite their increasing relevance for future treatment optimisation, neither the diversity of chronic and cumulative LE nor their pertinent risk factors and subsequent impact on quality of survival have yet been comprehensively addressed for CBTS treated according to HIT- or SIOP-E-protocols. Evidence-based information to empower survivors and stakeholders, as well as medical expertise to manage their individual health care, psychosocial and educational/vocational needs must still be generated and established. CONCLUSION The establishment of a long-term research- and care network in Germany shall contribute to a European platform, that aims at optimising CBTSs' transition into adulthood as resilient individuals with high quality of survival including optimal levels of activity, participation and acceptance by society.
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Affiliation(s)
- Gesche Tallen
- Department of Paediatric Oncology/Haematology, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany; Department of Paediatrics, Faculty of Medicine, University of Calgary, 2888 Shaganappi Trail N.W., Calgary, Alberta T3B 6A8, Canada.
| | - Anika Resch
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Gabriele Calaminus
- Department of Paediatric Haematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Andreas Wiener
- Department of Paediatric Haematology and Oncology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany.
| | - Ulrike Leiss
- Medical University Vienna, Department of Paediatric and Adolescent Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Thomas Pletschko
- Medical University Vienna, Department of Paediatric and Adolescent Medicine, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Carsten Friedrich
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany; Division of Paediatric Oncology, Haematology and Haemostaseology, Department of Woman's and Children's Health, University Hospital Leipzig, Liebigstr. 20a, 04103 Leipzig, Germany.
| | - Thorsten Langer
- Department of Paediatric Oncology/Haematology, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.
| | - Desiree Grabow
- German Childhood Cancer Registry (GCCR), Institute of Medical Biostatistics, Epidemiology, and Informatics (IMBEI), University Medical Center, University of Mainz, Gebäude 902, Obere Zahlbacher Straße 69, 55131 Mainz, Germany.
| | - Pablo Hernáiz Driever
- Department of Paediatric Oncology/Haematology, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Rolf-Dieter Kortmann
- Department of Radiation Oncology, University of Leipzig, Stephanstr. 9a, 04103 Leipzig, Germany.
| | - Beate Timmermann
- Particle Therapy Clinic at West German Proton Therapy Centre Essen, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Torsten Pietsch
- Institute of Neuropathology, University of Bonn, Sigmund-Freud-Str. 25, 53105 Bonn, Germany.
| | - Monika Warmuth-Metz
- Dept. of Neuroradiology, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Brigitte Bison
- Dept. of Neuroradiology, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Ulrich-Wilhelm Thomale
- Department of Paediatric Neurosurgery, Charité-Universitätsmedizin Berlin, Campus Virchow, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - Jürgen Krauss
- Department of Neurosurgery, Head Clinic, University of Würzburg, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Martin Mynarek
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Katja von Hoff
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Holger Ottensmeier
- University Children's Hospital Würzburg, Dept. of Paed. Haematology, Oncology, Josef-Schneider-Str. 2, 97080 Würzburg, Germany.
| | - Michael Frühwald
- Department of Paediatric Oncology/Haematology, Klinikum Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany.
| | - Christof M Kramm
- Division of Paediatric Haematology and Oncology, University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany.
| | - Petra Temming
- Paediatric Haematology/Oncology, Paediatrics III, University of Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Hermann L Müller
- Paediatric Oncology/Haematology, Klinikum Oldenburg, Medical Campus University Oldenburg, Rahel-Straus-Str. 10, 26133 Oldenburg, Germany.
| | - Olaf Witt
- German Cancer Research Centre (DKFZ) and Department of Paediatric Oncology/Haematology, University of Heidelberg, Heidelberg, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany.
| | - Uwe Kordes
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
| | - Gudrun Fleischhack
- Paediatric Haematology/Oncology, Paediatrics III, University of Essen, Hufelandstr. 55, 45147 Essen, Germany.
| | - Astrid Gnekow
- Department of Paediatric Oncology/Haematology, Klinikum Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany.
| | - Stefan Rutkowski
- Department of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf (UKE), Martinistr. 52, 20246 Hamburg, Germany.
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Piskunov AK, Nikitin KV, Potapov AA. Cellular and molecular mechanisms of radiation-induced brain injury: can peripheral markers be detected? ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2015; 79:90-96. [PMID: 25945381 DOI: 10.17116/neiro201579190-96] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Investigation of the mechanisms of radiation-induced brain injury is a relevant fundamental objective of radiobiology and neuroradiology. Damage to the healthy brain tissue is the key factor limiting the application of radiation therapy in patients with nervous systems neoplasms. Furthermore, postradiation brain injury can be clinically indiscernible from continued tumor growth and requires differential diagnosis. Thus, there exists high demand for biomarkers of radiation effects on the brain in neurosurgery and radiobiology. These markers could be used for better understanding and quantifying the effects of ionizing radiation on brain tissues, as well as for elaborating personalized therapy. Despite the high demand, biomarkers of radiation-induced brain injury have not been identified thus far. The cellular and molecular mechanisms of the effect of ionizing radiation on the brain were analyzed in this review in order to identify potential biomarkers of radiation-induced injury to nervous tissue.
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Affiliation(s)
- A K Piskunov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - K V Nikitin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A A Potapov
- Burdenko Neurosurgical Institute, Moscow, Russia
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Ito M, Iwamoto I, Hirano H, Douchi T. Menstrual restoration in severe panhypopituitarism many years after cranial irradiation for suprasellar germinoma. Reprod Med Biol 2014; 14:131-134. [PMID: 29259410 DOI: 10.1007/s12522-014-0200-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 11/10/2014] [Indexed: 11/24/2022] Open
Abstract
Purpose We report a very rare case showing menstrual restoration in severe pan-hypopituitarism many years after cranial irradiation for suprasellar germinoma. Case A 30-year-old, almost primarily amenorrheic woman with severe panhypopituitarism presented with cyclic genital bleeding for the previous five months. She had menstruated once, when she was 13 years old. When she was 14 years old, she was diagnosed with a suprasellar germinoma measuring 10 mm in diameter, which led to diabetes insipidus. Cranial irradiation with a total dose of 24 Gy and chemotherapy resulted in complete tumor remission. She developed severe hypopituitarism [luteinizing hormone (LH) = 0.4 mIU/mL, follicle-stimulating hormone (FSH) = 1.7 mIU/mL, and serum estradiol (E2) level < 10 pg/mL]. She had received multiple hormone replacement therapies for many years. When she was 29 years old, she expressed a desire to become pregnant. Serum gonadotropin and E2 levels increased (LH = 5.8 mIU/mL, FSH = 5.9 mIU/mL, and E2 = 58 pg/mL). She conceived with clomiphene therapy, and then delivered a healthy baby. Eight months after parturition, her basal body temperature and serum progesterone levels indicated recovery of ovulatory cycles. Ten months after parturition, she also spontaneously conceived. Conclusion Menstrual restoration is very rare in severe panhypopituitarism after cranial irradiation. A relatively low dose of irradiation and small tumor size may have contributed to the recovery of menstruation in our patient.
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Affiliation(s)
- Masanobu Ito
- Department of Obstetrics and Gynecology, Faculty of Medicine Kagoshima University Sakuragaoka 8-35-1890-8520 Kagoshima Japan
| | - Ichiro Iwamoto
- Department of Obstetrics and Gynecology, Faculty of Medicine Kagoshima University Sakuragaoka 8-35-1890-8520 Kagoshima Japan
| | - Hirofumi Hirano
- Department of Neurosurgery, Faculty of Medicine Kagoshima University 8-35-1 Sakuragaoka 890-8520 Kagoshima Japan
| | - Tsutomu Douchi
- Department of Obstetrics and Gynecology, Faculty of Medicine Kagoshima University Sakuragaoka 8-35-1890-8520 Kagoshima Japan
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Pituitary dysfunction in adult patients after cranial irradiation for head and nasopharyngeal tumours. Radiother Oncol 2014; 113:102-7. [DOI: 10.1016/j.radonc.2014.08.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 07/17/2014] [Accepted: 08/22/2014] [Indexed: 11/18/2022]
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