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Systematic Review and Meta-Analysis on the Use of Photon-based Stereotactic Radiosurgery Versus Fractionated Stereotactic Radiotherapy for the Treatment of Uveal Melanoma. Am J Clin Oncol 2020; 44:32-42. [DOI: 10.1097/coc.0000000000000775] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Baker S, Logie N, Paulson K, Duimering A, Murtha A. Radiotherapy for Brain Tumors: Current Practice and Future Directions. CURRENT CANCER THERAPY REVIEWS 2020. [DOI: 10.2174/1573394715666181129105542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Radiotherapy is an important component of the treatment for primary and metastatic
brain tumors. Due to the close proximity of critical structures and normal brain parenchyma, Central
Nervous System (CNS) radiotherapy is associated with adverse effects such as neurocognitive
deficits, which must be weighed against the benefit of improved tumor control. Advanced radiotherapy
technology may help to mitigate toxicity risks, although there is a paucity of high-level
evidence to support its use. Recent advances have been made in the treatment for gliomas, meningiomas,
benign tumors, and metastases, although outcomes remain poor for many high grade
tumors. This review highlights recent developments in CNS radiotherapy, discusses common
treatment toxicities, critically reviews advanced radiotherapy technologies, and highlights promising
treatment strategies to improve clinical outcomes in the future.
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Affiliation(s)
- Sarah Baker
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Natalie Logie
- University of Florida Proton Therapy Institute, Jacksonville, FL, United States
| | - Kim Paulson
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Adele Duimering
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada
| | - Albert Murtha
- Department of Radiation Oncology, Cross Cancer Institute, Edmonton, AB, Canada
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Apaydin T, Ozkaya HM, Durmaz SM, Meral R, Kadioglu P. Efficacy and Safety of Stereotactic Radiotherapy in Cushing's Disease: A Single Center Experience. Exp Clin Endocrinol Diabetes 2020; 129:482-491. [PMID: 32767284 DOI: 10.1055/a-1217-7365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of stereotactic radiotherapy (RT) in patients with Cushing's disease (CD). METHODS The study included 38 patients [31 patients who received gamma knife radiosurgery (GKS) and 7 patients who received cyberknife hypofractionated RT (HFRT)] with CD. Hormonal remission was considered if the patient had suppressed cortisol levels after low dose dexamethasone, normal 24-hour urinary free cortisol (UFC), and lack or regression of clinical features. RESULTS Biochemical control after RT was observed in 52.6% of the patients with CD and median time to hormonal remission was 15 months. Tumor size control was obtained in all of the patients. There was no significant relationship between remission rate and laboratory, radiological and pathological variables except for preoperative UFC. Remission rate was higher in patients with lower preoperative UFC. Time to remission increased in parallel to postoperative cortisol and 1mg DST level. Although medical therapy before RT did not affect the rate of- and time to remission, medical therapy after RT prolonged the time to hormonal remission. CONCLUSION In this current single center experience, postoperative cortisol and 1mg DST levels were found as the determinants of time to remission. Although medical therapy before RT did not affect the rate of- and time to remission, medical therapy after RT prolonged the time to biochemical control . This latter finding might suggest a radioprotective effect of cortisol lowering medication use on peri-RT period.
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Affiliation(s)
- Tugce Apaydin
- Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hande Mefkure Ozkaya
- Department of Endocrinology and Metabolism, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sebnem Memis Durmaz
- Department of Radiology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Rasim Meral
- Deparment of Radiation Oncology, Istanbul Medical School, Institute of Oncology, Istanbul University, Istanbul, Turkey
| | - Pinar Kadioglu
- Department of Endocrinology and Metabolism, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey.,Pituitary Center, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Chanson P, Maiter D. The epidemiology, diagnosis and treatment of Prolactinomas: The old and the new. Best Pract Res Clin Endocrinol Metab 2019; 33:101290. [PMID: 31326373 DOI: 10.1016/j.beem.2019.101290] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Prevalence and incidence of prolactinomas are approximately 50 per 100,000 and 3-5 new cases/100,000/year. The pathophysiological mechanism of hyperprolactinemia-induced gonadotropic failure involves kisspeptin neurons. Prolactinomas in males are larger, more invasive and less sensitive to dopamine agonists (DAs). Macroprolactin, responsible for pseudohyperprolactinemia is a frequent pitfall of prolactin assay. DAs still represent the primary therapy for most prolactinomas, but neurosurgery has regained interest, due to progress in surgical techniques and a high success rate in microprolactinoma, as well as to some underestimated side effects of long-term DA treatment, such as impulse control disorders or impaired quality of life. Recent data show that the suspected effects of DAs on cardiac valves in patients with prolactinomas are reassuring. Finally, temozolomide has emerged as a valuable treatment for rare cases of aggressive and malignant prolactinomas that do not respond to all other conventional treatments.
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Affiliation(s)
- Philippe Chanson
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Hôpital de Bicêtre, F-94275, Le Kremlin-Bicêtre, France; UMR-S1185 Université Paris-Sud, Univ Paris-Saclay, F-94276, Le Kremlin-Bicêtre, France; Institut National de la Santé et de la Recherche Médicale (Inserm) U1185, F-94276, Le Kremlin Bicêtre, France.
| | - Dominique Maiter
- Service d'Endocrinologie et Nutrition, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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Aggressive Pituitary Adenomas: The Dark Side of the Moon. World Neurosurg 2017; 97:140-155. [DOI: 10.1016/j.wneu.2016.09.092] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/18/2016] [Accepted: 09/23/2016] [Indexed: 01/14/2023]
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Patel J, Eloy JA, Liu JK. Nelson's syndrome: a review of the clinical manifestations, pathophysiology, and treatment strategies. Neurosurg Focus 2015; 38:E14. [PMID: 25639316 DOI: 10.3171/2014.10.focus14681] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nelson's syndrome is a rare clinical manifestation that occurs in 8%-47% of patients as a complication of bilateral adrenalectomy, a procedure that is used to control hypercortisolism in patients with Cushing's disease. First described in 1958 by Dr. Don Nelson, the disease has since become associated with a clinical triad of hyperpigmentation, excessive adrenocorticotropin secretion, and a corticotroph adenoma. Even so, for the past several years the diagnostic criteria and management of Nelson's syndrome have been inadequately studied. The primary treatment for Nelson's syndrome is transsphenoidal surgery. Other stand-alone therapies, which in many cases have been used as adjuvant treatments with surgery, include radiotherapy, radiosurgery, and pharmacotherapy. Prophylactic radiotherapy at the time of bilateral adrenalectomy can prevent Nelson's syndrome (protective effect). The most promising pharmacological agents are temozolomide, octreotide, and pasireotide, but these agents are often administered after transsphenoidal surgery. In murine models, rosiglitazone has shown some efficacy, but these results have not yet been found in human studies. In this article, the authors review the clinical manifestations, pathophysiology, diagnostic criteria, and efficacy of multimodal treatment strategies for Nelson's syndrome.
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Mak HKF, Lai SW, Qian W, Xu S, Tong E, Vance ML, Oldfield E, Jane J, Sheehan J, Yau KKW, Wintermark M. Effective time window in reducing pituitary adenoma size by gamma knife radiosurgery. Pituitary 2015; 18:509-17. [PMID: 25261330 DOI: 10.1007/s11102-014-0603-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Although the effectiveness of gamma knife radiosurgery (GKRS) in controlling the size of pituitary adenomas has been well demonstrated in many studies, the time period in which significant changes in tumor size occurs has been investigated in a limited fashion. It is important to determine the therapeutic window of GKRS in treating pituitary adenomas, i.e., the effective timeframe during which significant size reduction of these tumors occurs, so that alternative treatments such as further GKRS or microsurgery might be prescribed in a timely manner if clinically indicated. METHODS This was a nested sample of an ongoing local cohort study on GKRS for pituitary adenomas at the University of Virginia. Magnetic resonance imaging (MRI) using dedicated sequences was employed. Only patients with a baseline MRI (TP0) and at least 1 follow-up study performed in the University Hospital after GKRS were included. The follow-up scans were performed at five time-points (TP1-TP5) which were 6, 12, 24, 36 and 48 months after GKRS. The dimensional indices of the tumors were measured in three orthogonal planes, i.e., transverse (TR), antero-posterior (AP) and cranio-caudal (CC). The volumes of the tumors were estimated by using the following formula: [Formula: see text]. Tumor volume decrease by more than 25% from baseline was considered as 'shrinkage', <25% tumor size increase or decrease was considered 'static', and more than 25% increase as 'increment'. Our cohort consisted of 21 patients, with functioning adenomas in 13 subjects i.e. six adrenocorticotrophic hormone (ACTH)-secreting and seven growth hormone (GH)-secreting, and non-functioning (NF) adenomas in eight subjects. RESULTS In 26 adenomas (8 ACTH, 9 GH and 9 NF), tumor control (tumor shrinkage or static) were achieved in 21 tumors (80.8%); 89, 75, and 78% for GH-secreting, ACTH-secreting and NF adenomas respectively, at the end of the 4-year follow-up period. Analysis of variance showed significant differences of GKRS margin dose among different types of tumors (p = 0.013), but not of baseline tumor volumes (p = 0.240). Logistic regression analysis showed no significant association of margin dose, baseline volume or tumor type with the tumor control outcome. Comparison of tumor change using dimensional indices relative to the base time point (TP0) showed that in the sample there was an average reduction of 1.290 mm at TP1 (6 months) with p values 0.155 (parametric t test) and 0.098 (non-parametric Wilcoxon signed-ranked test) respectively, showing a moderate reduction in tumor dimensional indices. The change in dimensional indices at later time points (TP2-TP5) showed an average reduction ranging from 1.930 to 2.471 mm. Significant reduction in the mean dimensional indices was firstly observed at TP2 (1 year) with p values 0.013 (t test) and 0.018 (Wilcoxon signed-rank test). Such scale of reduction in the dimensional indices appeared to be maintained along the time axis (from TP2 to TP5). CONCLUSIONS Significant decrease in tumor dimensional indices tended to occur at 1 year post-GKRS. Although to a lesser extent, such decrease in dimensional indices continued up to the end of our follow-up period.
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Affiliation(s)
- Henry Ka-Fung Mak
- Department of Diagnostic Radiology, University of Hong Kong, Hong Kong Special Administrative Region, China
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Marek J, Ježková J, Hána V, Kršek M, Liščák R, Vladyka V, Pecen L. Gamma knife radiosurgery for Cushing's disease and Nelson's syndrome. Pituitary 2015; 18:376-84. [PMID: 25008022 DOI: 10.1007/s11102-014-0584-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE This paper presents our 18 years of experience in treating ACTH secreting adenomas (Cushing's disease and Nelson's syndrome) using the Leksell gamma knife (LGK) irradiation. METHODS Twenty-six patients with Cushing's disease were followed-up after LGK irradiation for 48-216 months (median 78 months). Seventeen patients had undergone previous surgery, in nine patients LGK irradiation was the primary therapy. Furthermore, 14 patients with Nelson's syndrome were followed-up for 30-204 months (median 144 months). RESULTS LGK treatment resulted in hormonal normalization in 80.7 % of patients with Cushing's disease. Time to normalization was 6-54 months (median 30 months). The volume of the adenoma decreased in 92.3% (in 30.7% disappeared completely). There was no recurrence of the disease. In all 14 patients with Nelson's syndrome ACTH levels decreased (in two patients fully normalized) their ACTH levels. When checked up 5-10 years after irradiation regrowth of the adenoma was only detected in one patient (9.1%), in 27.3% adenoma volume remained unchanged, in 45.4% adenoma volume decreased and in 18.2% adenoma completely disappeared. Hypopituitarism did not develop in any patient where the critical dose to the pituitary and distal infundibulum was respected. CONCLUSION LGK radiation represents an effective and well-tolerated option for the treatment of patients with Cushing's disease after unsuccessful surgery and may be valuable even as a primary treatment in patients who are not suitable for, or refuse, surgery. In the case of Nelson's syndrome it is possible to impede tumorous growth and control the size of the adenoma in almost all patients.
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Affiliation(s)
- Josef Marek
- Third Department of Medicine, First Medical Faculty, Charles University, U nemocnice 1, 128 02, Prague 2, Czech Republic
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Ritvonen E, Karppinen A, Sintonen H, Vehkavaara S, Kivipelto L, Roine RP, Niemelä M, Schalin-Jäntti C. Normal long-term health-related quality of life can be achieved in patients with functional pituitary adenomas having surgery as primary treatment. Clin Endocrinol (Oxf) 2015; 82:412-21. [PMID: 25039500 DOI: 10.1111/cen.12550] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 06/18/2014] [Accepted: 07/06/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Previous studies report impaired health-related quality of life (HRQoL) in patients with functional pituitary adenomas (FPA). We assessed HRQoL in FPA patients having undergone surgery at our University Central Hospital between 2000 and 2010, with combined adjuvant treatment given to achieve strict hormonal control. DESIGN A cross-sectional study including a large control population. PATIENTS AND METHODS HRQoL was assessed by the 15D in 100 FPA patients (acromegaly n = 47, Cushing's disease n = 21, prolactinoma n = 26, TSH-adenoma n = 2, gonadotropinoma n = 4), operated on a mean 7·4 (range 2·1-13·0) years earlier. An age- and gender-standardized sample of the general population (n = 4924) served as controls. HRQoL determinants were assessed by independent samples t-test and multiple regression analysis. RESULTS Hormonal remission rate was 90·9% and 43·9% of the patients received replacement therapy. The mean 15D scores were similar in patients and controls (0·917 vs 0·922, P = 0·568). On single dimensions, patients were worse off regarding speech and sexual activity (both P < 0·05) and better off regarding discomfort and symptoms (P < 0·05). Age (P = 0·001), co-morbidities (P = 0·009), Cushing's disease (P = 0·034), and thyroxine dose (P = 0·002) predicted impaired HRQoL, but not hypopituitarism, hydrocortisone replacement, radiotherapy, or time after surgery. CONCLUSIONS It is possible to achieve near-normal HRQoL in surgically treated FPA patients given adjuvant treatment to achieve strict hormonal remission. However, in addition to age and co-morbidities, Cushing's disease and need for thyroxine replacement therapy predict impaired HRQoL.
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Affiliation(s)
- Elina Ritvonen
- Division of Endocrinology, Department of Medicine, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
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Boström JP, Meyer A, Pintea B, Gerlach R, Surber G, Lammering G, Hamm K. Risk-adapted single or fractionated stereotactic high-precision radiotherapy in a pooled series of nonfunctioning pituitary adenomas: high local control and low toxicity. Strahlenther Onkol 2014; 190:1095-103. [PMID: 25091268 PMCID: PMC4240908 DOI: 10.1007/s00066-014-0715-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Accepted: 06/28/2014] [Indexed: 11/04/2022]
Abstract
Purpose The purpose of this work was to evaluate a prospectively initiated two-center protocol of risk-adapted single-fraction (SRS) or fractionated radiotherapy (SRT) in patients with nonsecretory pituitary adenomas (NSA). Patients and methods A total of 73 NSA patients (39 men/34 women) with a median age of 62 years were prospectively included in a treatment protocol of SRS [planning target volume (PTV) < 4 ccm, > 2 mm to optic pathways = low risk] or SRT (PTV ≥ 4 ccm, ≤ 2 mm to optic pathways = high risk) in two Novalis® centers. Mean tumor volume was 7.02 ccm (range 0.58–57.29 ccm). Based on the protocol guidelines, 5 patients were treated with SRS and 68 patients with SRT. Results Median follow-up (FU) reached 5 years with 5-year overall survival (OS) of 90.4 % (CI 80.2–95 %) and 5-year local control and progression-free survival rates of 100 % (CI 93.3–100 %) and 90.4 % (CI 80.2–95 %), respectively. A post-SRS/SRT new visual disorder occurred in 2 patients (2.7 %), a new oculomotor nerve palsy in one pre-irradiated patient, in 3 patients (4.1 %) a pre-existing visual disorder improved. New complete hypopituitarism occurred in 4 patients (13.8 %) and in 3 patients (25 %) with pre-existing partial hypopituitarism. Pituitary function in 26 % of patients retained normal. Patients with tumor shrinkage (65.75 %) had a significantly longer FU (p = 0.0093). Multivariate analysis confirmed correlation of new hypopituitarism with duration of FU (p = 0.008) and correlation of new hypopituitarism and tumor volume (p = 0.023). No significant influence factors for occurrence of visual disorders were found. Conclusion Our SRS/SRT protocol proved to be safe and successful in terms of tumor control and protection of the visual system, especially for large tumors located close to optic pathways.
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Affiliation(s)
- Jan Patrick Boström
- Department of Radiosurgery and Stereotactic Radiotherapy, MediClin Robert Janker Clinic and MediClin MVZ Bonn, Villenstrasse 8, 53129, Bonn, Germany,
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Samarasinghe S, Emanuele MA, Mazhari A. Neurology of the pituitary. NEUROLOGIC ASPECTS OF SYSTEMIC DISEASE PART II 2014; 120:685-701. [DOI: 10.1016/b978-0-7020-4087-0.00047-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Halperin Rabinovich I, Cámara Gómez R, García Mouriz M, Ollero García-Agulló D. [Clinical guidelines for diagnosis and treatment of prolactinoma and hyperprolactinemia]. ACTA ACUST UNITED AC 2013; 60:308-19. [PMID: 23477758 DOI: 10.1016/j.endonu.2012.11.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Accepted: 11/26/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To provide practical and up to date recommendations for evaluation, differential diagnosis, and treatment of prolactinoma and hyperprolactinemia in various clinical settings. PARTICIPANTS Members of the Neuroendocrinology Working Group of the Spanish Society of Endocrinology. METHODS Recommendations were formulated according to the Grading of Recommendations, Assessment, Development, and Evaluation system (GRADE) to describe both the strength of recommendations and the quality of evidence. A systematic search was made in Medline (Pubmed) for each subject, and authors' considerations were added in areas where the literature provided scarce evidence. Finally, recommendations were jointly discussed by the Working Group. CONCLUSIONS The document provides evidence-based practical and updated recommendations for diagnosis and management of hyperprolactinemia and prolactinoma, including drug-induced hyperprolactinemia, treatment options for prolactinoma (drugs, surgery, and radiotherapy), prolactinoma in pregnancy, adverse effects of dopaminergic agents, and drug-resistant and malignant prolactinomas.
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Affiliation(s)
- Irene Halperin Rabinovich
- Servicio de Endocrinología y Nutrición, Hospital Clínic, Universitat de Barcelona, Barcelona, España.
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Minniti G, Goldsmith C, Brada M. Radiotherapy. HANDBOOK OF CLINICAL NEUROLOGY 2012; 104:215-28. [PMID: 22230446 DOI: 10.1016/b978-0-444-52138-5.00016-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Minniti G, Scaringi C, Amelio D, Maurizi Enrici R. Stereotactic Irradiation of GH-Secreting Pituitary Adenomas. Int J Endocrinol 2012; 2012:482861. [PMID: 22518123 PMCID: PMC3296430 DOI: 10.1155/2012/482861] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Accepted: 12/14/2011] [Indexed: 01/02/2023] Open
Abstract
Radiotherapy (RT) is often employed in patients with acromegaly refractory to medical and/or surgical interventions in order to prevent tumour regrowth and normalize elevated GH and IGF-I levels. It achieves tumour control and hormone normalization up to 90% and 70% of patients at 10-15 years. Despite the excellent tumour control, conventional RT is associated with a potential risk of developing late toxicity, especially hypopituitarism, and its role in the management of patients with GH-secreting pituitary adenomas remains a matter of debate. Stereotactic techniques have been developed with the aim to deliver more localized irradiation and minimize the long-term consequences of treatment, while improving its efficacy. Stereotactic irradiation can be given in a single dose as stereotactic radiosurgery (SRS) or in multiple doses as fractionated stereotactic radiotherapy (FSRT). We have reviewed the recent published literature on stereotactic techniques for GH-secreting pituitary tumors with the aim to define the efficacy and potential adverse effects of each of these techniques.
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Affiliation(s)
- G. Minniti
- Department of Neuroscience, Neuromed Institute, 86077 Pozzilli, Italy
- Department of Radiation Oncology, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy
- *G. Minniti:
| | - C. Scaringi
- Department of Radiation Oncology, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy
| | - D. Amelio
- ATreP, Agenzia Provinciale per la Protonterapia, 38122 Trento, Italy
| | - R. Maurizi Enrici
- Department of Radiation Oncology, Sant'Andrea Hospital, University Sapienza, 00189 Rome, Italy
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Minniti G, Scaringi C, Enrici RM. Radiation techniques for acromegaly. Radiat Oncol 2011; 6:167. [PMID: 22136376 PMCID: PMC3275813 DOI: 10.1186/1748-717x-6-167] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2011] [Accepted: 12/02/2011] [Indexed: 11/28/2022] Open
Abstract
Radiotherapy (RT) remains an effective treatment in patients with acromegaly refractory to medical and/or surgical interventions, with durable tumor control and biochemical remission; however, there are still concerns about delayed biochemical effect and potential late toxicity of radiation treatment, especially high rates of hypopituitarism. Stereotactic radiotherapy has been developed as a more accurate technique of irradiation with more precise tumour localization and consequently a reduction in the volume of normal tissue, particularly the brain, irradiated to high radiation doses. Radiation can be delivered in a single fraction by stereotactic radiosurgery (SRS) or as fractionated stereotactic radiotherapy (FSRT) in which smaller doses are delivered over 5-6 weeks in 25-30 treatments. A review of the recent literature suggests that pituitary irradiation is an effective treatment for acromegaly. Stereotactic techniques for GH-secreting pituitary tumors are discussed with the aim to define the efficacy and potential adverse effects of each of these techniques.
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Affiliation(s)
- Giuseppe Minniti
- Department of Neuroscience, Neuromed Institute, Pozzilli, IS, Italy.
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Katznelson L, Atkinson JLD, Cook DM, Ezzat SZ, Hamrahian AH, Miller KK. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of acromegaly--2011 update. Endocr Pract 2011; 17 Suppl 4:1-44. [PMID: 21846616 DOI: 10.4158/ep.17.s4.1] [Citation(s) in RCA: 156] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Affiliation(s)
- Laurence Katznelson
- Departments of Medicine and Neurosurgery, Stanford University, Stanford, California, USA
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Zahajszky J, Quinn DK, Smith FA, Stern TA. Cognitive and perceptual disturbances in a young man. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 9:59-63. [PMID: 17599171 PMCID: PMC1894835 DOI: 10.4088/pcc.v09n0111] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Minniti G, Clarke E, Cavallo L, Osti MF, Esposito V, Cantore G, Cappabianca P, Enrici RM. Fractionated stereotactic conformal radiotherapy for large benign skull base meningiomas. Radiat Oncol 2011; 6:36. [PMID: 21486436 PMCID: PMC3094366 DOI: 10.1186/1748-717x-6-36] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 04/12/2011] [Indexed: 11/16/2022] Open
Abstract
Purpose to assess the safety and efficacy of fractionated stereotactic radiotherapy (FSRT) for large skull base meningiomas. Methods and Materials Fifty-two patients with large skull base meningiomas aged 34-74 years (median age 56 years) were treated with FSRT between June 2004 and August 2009. All patients received FSRT for residual or progressive meningiomas more than 4 centimeters in greatest dimension. The median GTV was 35.4 cm3 (range 24.1-94.9 cm3), and the median PTV was 47.6 cm3 (range 33.5-142.7 cm3). Treatment volumes were achieved with 5-8 noncoplanar beams shaped using a micromultileaf collimator (MLC). Treatment was delivered in 30 daily fractions over 6 weeks to a total dose of 50 Gy using 6 MV photons. Outcome was assessed prospectively. Results At a median follow-up of 42 months (range 9-72 months) the 3-year and 5-year progression-free survival (PFS) rates were 96% and 93%, respectively, and survival was 100%. Three patients required further debulking surgery for progressive disease. Hypopituitarism was the most commonly reported late complication, with a new hormone pituitary deficit occurring in 10 (19%) of patients. Clinically significant late neurological toxicity was observed in 3 (5.5%) patients consisting of worsening of pre-existing cranial deficits. Conclusion FSRT as a high-precision technique of localized RT is suitable for the treatment of large skull base meningiomas. The local control is comparable to that reported following conventional external beam RT. Longer follow-up is required to assess long term efficacy and toxicity, particularly in terms of potential reduction of treatment-related late toxicity.
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Affiliation(s)
- Giuseppe Minniti
- Department of Radiation Oncology, Sant' Andrea Hospital, Università degli Studi di Roma La Sapienza, Rome, Italy.
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Management of nonpsychiatric medical conditions presenting with psychiatric manifestations. Pediatr Clin North Am 2011; 58:219-41, xii. [PMID: 21281858 DOI: 10.1016/j.pcl.2010.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There is a significant dilemma when underlying medical disorders present as psychiatric conditions. It is important to identify the medical condition because treatment and management strategies need to be directed to the presenting symptoms and also to the underlying medical condition for successful treatment of the patient. Some systemic disorders present with psychiatric manifestations more often than others. The pattern of psychiatric disturbance seen may be specific for a particular medical disorder but may also be varied. Many drug formulations and medications also may produce psychiatric presentations. This article considers the management of nonpsychiatric medical conditions presenting with psychiatric manifestations.
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Abstract
The high morbidity and mortality associated with acromegaly can be addressed with multiple treatment modalities, including surgery, medicines, and radiation therapy. Radiation was initially delivered through conventional fractionated radiotherapy, which targets a wide area over many treatment sessions and has been shown to induce remission in 50%–60% of patients with acromegaly. However, conventional fractionated radiotherapy takes several years to achieve remission in patients with acromegaly and carries a risk of hypopituitarism that may limit its use. Stereotactic radiosurgery, of which there are several forms, including Gamma Knife surgery, CyberKnife therapy, and proton beam therapy, offers slightly attenuated efficacy but achieves remission in less time and provides more precise targeting of the adenoma with better control of the dose of radiation received by adjacent structures such as the pituitary stalk, pituitary gland, optic chiasm, and cranial nerves in the cavernous sinus. Of the forms of stereotactic radiosurgery, Gamma Knife surgery is the most widely used and, because of its long-term follow-up in clinical studies, is the most likely to compete with medical therapy for first-line adjuvant use after resection. In this review, the authors outline the major modes of radiation therapies in clinical use today, and they critically assess the feasibility of these modalities for acromegaly treatment. Acromegaly is a multisystem disorder that demands highly specialized treatment protocols including neurosurgical and endocrinological intervention. As more efficient forms of pituitary radiation develop, acromegaly treatment options may continue to change with radiation therapies playing a more prominent role.
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Affiliation(s)
- Nathan C Rowland
- Department of Neurological Surgery, California Center for Pituitary Disorders, University of California, San Francisco, California 94143-0112, USA
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Castro DG, Cecílio SAJ, Canteras MM. Radiosurgery for pituitary adenomas: evaluation of its efficacy and safety. Radiat Oncol 2010; 5:109. [PMID: 21083925 PMCID: PMC2994872 DOI: 10.1186/1748-717x-5-109] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2010] [Accepted: 11/17/2010] [Indexed: 11/30/2022] Open
Abstract
Object To assess the effects of radiosurgery (RS) on the radiological and hormonal control and its toxicity in the treatment of pituitary adenomas. Methods Retrospective analysis of 42 patients out of the first 48 consecutive patients with pituitary adenomas treated with RS between 1999 and 2008 with a 6 months minimum follow-up. RS was delivered with Gamma Knife as a primary or adjuvant treatment. There were 14 patients with non-secretory adenomas and, among functioning adenomas, 9 were prolactinomas, 9 were adrenocorticotropic hormone-secreting and 10 were growth hormone-secreting tumors. Hormonal control was defined as hormonal response (decline of more than 50% from the pre-RS levels) and hormonal normalization. Radiological control was defined as stasis or shrinkage of the tumor. Hypopituitarism and visual deficit were the morbidity outcomes. Hypopituitarism was defined as the initiation of any hormone replacement therapy and visual deficit as loss of visual acuity or visual field after RS. Results The median follow-up was 42 months (6-109 months). The median dose was 12,5 Gy (9 - 15 Gy) and 20 Gy (12 - 28 Gy) for non-secretory and secretory adenomas, respectively. Tumor growth was controlled in 98% (41 in 42) of the cases and tumor shrinkage ocurred in 10% (4 in 42) of the cases. The 3-year actuarial rate of hormonal control and normalization were 62,4% and 37,6%, respectively, and the 5-year actuarial rate were 81,2% and 55,4%, respectively. The median latency period for hormonal control and normalization was, respectively, 15 and 18 months. On univariate analysis, there were no relationships between median dose or tumoral volume and hormonal control or normalization. There were no patients with visual deficit and 1 patient had hypopituitarism after RS. Conclusions RS is an effective and safe therapeutic option in the management of selected patients with pituitary adenomas. The short latency of the radiation response, the highly acceptable radiological and hormonal control and absence of complications at this early follow-up are consistent with literature.
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Affiliation(s)
- Douglas G Castro
- Institute of Neurological Radiosurgery (IRCN), Alvorada street, 64, suit 13/14, São Paulo-SP, ZIP: 04550-000, Brazil.
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Multidisciplinary treatment of giant invasive prolactinomas in paediatric age: long-term follow-up in two children. Childs Nerv Syst 2010; 26:1233-7. [PMID: 20352234 DOI: 10.1007/s00381-010-1129-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Accepted: 03/10/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Invasive giant prolactinomas are rare tumours, still representing a therapeutic challenge due to their characteristics of invasiveness and variable clinical course. Giant prolactinomas in childhood are extremely rare. Only single case reports have been described in the literature. CASE PRESENTATION We report on two children who presented a progressive visual deterioration. Magnetic resonance imaging showed extensive intra-suprasellar tumour invading the anterior skull base. The laboratory investigations detected markedly elevated prolactin levels. The patients were firstly started on dopamine agonist therapy with partial reduction in size of the tumours. The debulking of the residual lesions through a transsphenoidal approach was then performed in both patients, one of whom requiring a second surgical procedure for tumour regrowth. The complete shrinkage of the residual adenomas was achieved after the treatment with conventional radiotherapy, with a follow-up of 13 and 14 years, respectively. DISCUSSION Multidisciplinary therapeutic approach for giant prolactinomas in paediatric patients can be an effective treatment; despite the invasiveness of these tumours, the efficacy of this combined treatment can reach a satisfactory control of the disease at long term, assuring a good quality of life as well.
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Di Mambro A, Giuliani C, Ammannati F, Mannucci E, Scoccianti S, Detti B, Meattini I, Mennonna P, Forti G, Serio M, Peri A. A single-institution restrospective experience of brachytherapy in the treatment of pituitary tumors: transsphenoidal approach combined with (192)Ir-afterloading catheters. J Endocrinol Invest 2010; 33:455-60. [PMID: 19955849 DOI: 10.1007/bf03346624] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND AIM Radiotherapy may be used as an adjuvant treatment of pituitary adenomas. The aim of our study was to present our experience of multimodal treatment of pituitary adenomas, consisting in temporary implantation of (192)Ir-labeled wires following transphenoidal surgery. SUBJECTS AND METHODS An observational investigation was performed on a series of 80 patients undergoing surgery (S) for pituitary adenomas between 1982 and 2000, some of whom received post-operative external beam radiotherapy (EBRT) (no.=19 between 1982 and 1990), brachytherapy (B) (no.=35, all after 1991), or both irradiation modalities (EBRT+B) (no.=14). The different treatments were compared in terms of hormonal normalization in the subgroup of patients with hypersecreting adenomas, tumor control, and side effects. RESULTS Hormonal normalization was obtained in 84% of S+B patients and in 61% of S+EBRT patients. Tumor control was obtained in 74.3% of S+B patients and in 63.1% of S+EBRT patients. Anterior pituitary hormones deficits ranged from 8.6-34% in S+B patients and from 15.8-47.4% in S+EBRT patients, after a mean follow-up of 14 yr. The latter group also showed a higher rate of multiple deficits (42.1% vs 22.8%). Diabetes insipidus and other major complications were rare events in all groups. CONCLUSIONS We presented one original experience regarding brachytherapy in the management of pituitary tumors, which turned out to be effective and safe. Additional prospective, and possibly randomized, studies should clarify whether in the era of 3-dimensional conformal radiotherapy and stereotactic radiotherapy this treatment modality may still have a role.
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Affiliation(s)
- A Di Mambro
- Endocrine Unit, Department of Clinical Physiopathology, Center for Research, Transfer and High Education on Chronic, Inflammatory, Degenerative and Neoplastic Disorders for the Development of Novel Therapies (DENOThe), University of Florence, Viale Pieraccini 6, 50139 Florence, Italy
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Castinetti F, Régis J, Dufour H, Brue T. Role of stereotactic radiosurgery in the management of pituitary adenomas. Nat Rev Endocrinol 2010; 6:214-23. [PMID: 20177403 DOI: 10.1038/nrendo.2010.4] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Trans-sphenoidal neurosurgery is the gold standard treatment for pituitary adenomas, but it can be contraindicated or ineffective. Stereotactic radiosurgery is a procedure aimed at controlling hormone hypersecretion and tumor size of pituitary adenomas. This Review discusses the long-term efficacy and adverse effects of stereotactic radiosurgery with the Gamma Knife((R)) in secreting and nonsecreting pituitary adenomas. Long-term data confirm the antisecretory efficacy of the procedure (about 50% remission in hypersecreting tumors) but also a previously unknown low risk of recurrence (2-10% of cases). The time to remission is estimated to range from 12 to 60 months. The antitumoral efficacy of this treatment against nonsecreting tumors is observed in about 90% of cases. Hypopituitarism is the main adverse effect, observed in 20-40% of cases. Comparisons with conventional fractionated radiotherapy reveal a lower rate of remission with Gamma Knife((R)) radiosurgery, counterbalanced by a more rapid efficacy and a lower rate of hypopituitarism. Short-term follow-up results on stereotactic fractionated radiotherapy suggest a risk of hypopituitarism similar to the one observed with radiosurgery. Therefore, stereotactic radiosurgery is probably still useful to treat some cases of pituitary adenoma, despite the fact that antisecretory drugs, particularly for acromegaly and prolactinomas, are becoming more effective and are well tolerated, thus increasing the probability of success with nonsurgical therapy.
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Affiliation(s)
- Frederic Castinetti
- Centre de Réference des Maladies Rares d'Origine Hypophysaire, Service d'Endocrinologie, Diabète et Maladies Métaboliques, Hôpital de la Timone, Assistance Publique Hôpitaux de Marseille, Rue St Pierre, Université de la Mediterranée, Marseille Cedex 05, France.
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Elhateer H, Muanza T, Roberge D, Ruo R, Eldebawy E, Lambert C, Patrocinio H, Shenouda G, Souhami L. Fractionated stereotactic radiotherapy in the treatment of pituitary macroadenomas. ACTA ACUST UNITED AC 2010; 15:286-92. [PMID: 19079630 PMCID: PMC2601024 DOI: 10.3747/co.v15i6.293] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background The use of fractionated stereotactic radiotherapy (fsrt) has evolved with technical advances in noninvasive immobilization, radiation delivery, and image guidance. The application of fsrt to pituitary tumours is aimed at reducing toxicity through improved dose conformality and reduced treatment margins. The aim of the present paper is to report our own experience and to review the published data on fsrt for pituitary macroadenomas. Methods Between September 2000 and October 2005, 13 patients with pituitary macroadenoma underwent fsrt at our institution. In 12 patients, radiotherapy treatment followed surgical resection (transsphenoidal resection in 8, frontal craniotomy in 3, and multiple transsphenoidal resections followed by craniotomy in 1). In 4 patients, the tumours were functional (2 adrenocorticotropic hormone–secreting, 1 prolactinoma, and 1 growth hormone–secreting); the tumours in the remaining patients were clinically non-secretory. Before radiation, 3 patients had panhypopituitarism, and 6 patients had visual field defects. All patients were treated with fsrt using non-coplanar micro–multileaf collimation portals. A median dose of 50.4 Gy (range: 45–60 Gy) was prescribed to the 76.9%–95.2% isodose surface and delivered in 1.8-Gy fractions. The median planning target volume (gross tumour plus 3 mm) was 33.5 cm3 (range: 3.2–75 cm3). Results After a median follow-up of 24 months (range: 6–60 months), local control was 100%. One patient achieved clinical complete response. Treatment was well tolerated acutely for all patients. Neither radiation-induced optic neuropathy nor any radiation-related endocrine dysfunction was observed in our patients. Conclusions In accordance with published series, we found fsrt to be safe and effective in the management of large pituitary macroadenomas.
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Affiliation(s)
- H Elhateer
- Department of Radiation Oncology, McGill University Health Center, Montreal, QC
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Minniti G, Valeriani M, Clarke E, D'Arienzo M, Ciotti M, Montagnoli R, Saporetti F, Enrici RM. Fractionated stereotactic radiotherapy for skull base tumors: analysis of treatment accuracy using a stereotactic mask fixation system. Radiat Oncol 2010; 5:1. [PMID: 20070901 PMCID: PMC2823752 DOI: 10.1186/1748-717x-5-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Accepted: 01/13/2010] [Indexed: 11/20/2022] Open
Abstract
Background To assess the accuracy of fractionated stereotactic radiotherapy (FSRT) using a stereotactic mask fixation system. Patients and Methods Sixteen patients treated with FSRT were involved in the study. A commercial stereotactic mask fixation system (BrainLAB AG) was used for patient immobilization. Serial CT scans obtained before and during FSRT were used to assess the accuracy of patient immobilization by comparing the isocenter position. Daily portal imaging were acquired to establish day to day patient position variation. Displacement errors along the different directions were calculated as combination of systematic and random errors. Results The mean isocenter displacements based on localization and verification CT imaging were 0.1 mm (SD 0.3 mm) in the lateral direction, 0.1 mm (SD 0.4 mm) in the anteroposterior, and 0.3 mm (SD 0.4 mm) in craniocaudal direction. The mean 3D displacement was 0.5 mm (SD 0.4 mm), being maximum 1.4 mm. No significant differences were found during the treatment (P = 0.4). The overall isocenter displacement as calculated by 456 anterior and lateral portal images were 0.3 mm (SD 0.9 mm) in the mediolateral direction, -0.2 mm (SD 1 mm) in the anteroposterior direction, and 0.2 mm (SD 1.1 mm) in the craniocaudal direction. The largest displacement of 2.7 mm was seen in the cranio-caudal direction, with 95% of displacements < 2 mm in any direction. Conclusions The results indicate that the setup error of the presented mask system evaluated by CT verification scans and portal imaging are minimal. Reproducibility of the isocenter position is in the best range of positioning reproducibility reported for other stereotactic systems.
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Affiliation(s)
- Giuseppe Minniti
- Department of Radiation Oncology, Sant' Andrea Hospital, University La Sapienza, via di Grottarossa 1035-1039, 00189, Rome, Italy.
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Minniti G, Amichetti M, Enrici RM. Radiotherapy and radiosurgery for benign skull base meningiomas. Radiat Oncol 2009; 4:42. [PMID: 19828022 PMCID: PMC2768735 DOI: 10.1186/1748-717x-4-42] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Accepted: 10/14/2009] [Indexed: 11/28/2022] Open
Abstract
Meningiomas located in the region of the base of skull are difficult to access. Complex combined surgical approaches are more likely to achieve complete tumor removal, but frequently at a cost of treatment related high morbidity. Local control following subtotal excision of benign meningiomas can be improved with conventional fractionated external beam radiation therapy with a reported 5-year progression-free survival up to 95%. New radiation techniques, including stereotactic radiosurgery (SRS), fractionated stereotactic radiotherapy (FSRT), and intensity-modulated radiotherapy (IMRT) have been developed as a more accurate technique of irradiation with more precise tumor localization, and consequently a reduction in the volume of normal brain irradiated to high radiation doses. SRS achieves a high tumour control rate in the range of 85-97% at 5 years, although it should be recommended only for tumors less than 3 cm away more than 3 mm from the optic pathway because of high risk of long-term neurological deficits. Fractionated RT delivered as FSRT, IMRT and protons is useful for larger and irregularly or complex-shaped skull base meningiomas close to critical structures not suitable for single-fraction SRS. The reported results indicate a high tumour control rate in the range of 85-100% at 5 years with a low risk of significant incidence of long-term toxicity. Because of the long natural history of benign meningiomas, larger series and longer follow-up are necessary to compare results and toxicity of different techniques.
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Affiliation(s)
- Giuseppe Minniti
- Department of Radiotherapy Oncology, Sant' Andrea Hospital, University La Sapienza, Rome, Italy.
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Abstract
This review focus on the epidemiology, diagnosis and treatment of prolactinomas. In particular, attention was given to recent data showing a high prevalence of these tumours in the general population, 3-5 times higher than previously reported. The diagnosis of hyperprolactinaemia has been simplified in recent years, and only prolactin (PRL) assay and magnetic resonance imaging of the sella are required. Nonetheless, macroprolactinaemia should be assessed in patients with hyperprolactinaemia in the absence of clinical symptoms of elevated PRL levels. The recent evidence that medical therapy with dopamine agonists should be continued lifelong has been confirmed by several studied. The patients achieving disappearance of the tumours and suppression of PRL levels during treatment are those showing the highest likelihood to have persistent remission of hyperprolactinaemia after treatment withdrawal.
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Affiliation(s)
- Annamaria Colao
- Department of Molecular and Clinical Endocrinology and Oncology, Federico II University, via S. Pansini 5, 80131 Naples, Italy.
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Castinetti F, Nagai M, Morange I, Dufour H, Caron P, Chanson P, Cortet-Rudelli C, Kuhn JM, Conte-Devolx B, Regis J, Brue T. Long-term results of stereotactic radiosurgery in secretory pituitary adenomas. J Clin Endocrinol Metab 2009; 94:3400-7. [PMID: 19509108 DOI: 10.1210/jc.2008-2772] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT To date, no study reported long-term follow-up results of gamma knife stereotactic radiosurgery (SR). OBJECTIVE The aim of the study was to determine long-term efficacy and adverse effects of SR in secreting pituitary adenomas. DESIGN We conducted a retrospective study of patients treated by SR in the center of Marseille, France, with a follow-up of at least 60 months. PATIENTS A total of 76 patients were treated by SR for acromegaly (n = 43), Cushing's disease (CD; n = 18), or prolactinoma (n = 15) as a primary (n = 27) or adjunctive postsurgical treatment (n = 49). MAIN OUTCOME MEASURES After withdrawal of antisecretory drugs, patients were considered in remission if they had mean GH levels below 2 ng/ml and normal IGF-I (acromegaly), normal 24-h urinary free cortisol, and cortisol less than 50 nmol/liter after low-dose dexamethasone test (CD) or two consecutive normal samplings of prolactin levels (prolactinoma). RESULTS After a mean follow-up of 96 months, 44.7% of the patients were in remission. Mean time to remission was 42.6 months. Twelve patients presented late remission at least 48 months after SR. Two patients with CD presented late recurrence 72 and 96 months after SR. Forty percent of patients treated primarily with SR were in remission. Target volume and initial hormone levels were significant predictive factors of remission in univariate analysis. Radiation-induced hypopituitarism was observed in 23% patients; in half of them, hypopituitarism was observed after a mean time of 48 to 96 months. Twenty-four patients were followed for more than 120 months; rates of remission and hypopituitarism were similar to the whole cohort. CONCLUSIONS SR is an effective and safe primary or adjunctive treatment in selected patients with secreting pituitary adenomas.
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Affiliation(s)
- Frederic Castinetti
- Service d'Endocrinologie, Diabète, et Maladies Métaboliques, et Centre de Reference des Maladies Rares d'Origine Hypophysaires, Hôpital de la Timone, F-13385 Marseille, France
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Non-surgical management of hormone-secreting pituitary tumors. J Clin Neurosci 2009; 16:985-93. [DOI: 10.1016/j.jocn.2008.11.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2008] [Revised: 11/07/2008] [Accepted: 11/10/2008] [Indexed: 11/18/2022]
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Abstract
Hyperprolactinaemia is a common condition with varied aetiology. It is more frequent in women, but also seen in men and even in adolescence and childhood. Prolactin is mainly a lactogenic hormone but has other actions. Most cases present with amenorrhoea and infertility and are managed by gynaecologists. However, multidisciplinary involvement may be required in some cases. Evidence relating to aetiology, clinical features, pathogenesis and management has been discussed.
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Abstract
Radiotherapy (RT) remains an effective treatment for residual or recurrent pituitary adenomas with excellent rates of tumour control and normalisation of excess hormone secretion. The main late toxicity is hypopituitarism: other side effects are rare. We discuss technical developments in the delivery of radiotherapy (stereotactic conformal radiotherapy (SCRT) and stereotactic radiosurgery (SRS)), all aiming to reduce the amount of normal brain receiving significant doses of radiation. We provide a comprehensive review of published data on outcome of conventional fractionated radiotherapy and modern RT techniques. SCRT is a suitable treatment technique for all sizes of pituitary adenoma and efficacy is comparable to conventional RT; the lack of long term follow up means that currently there is no information on potential reduction in the incidence of late radiation induced toxicity. Single fraction SRS can only be safely delivered to small tumours away from critical structures. There is no evidence that it produces faster decline of elevated hormone levels than fractionated treatment and is not associated with lesser morbidity.
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Affiliation(s)
- G Minniti
- Neuro-oncology Unit, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, Surrey, UK
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Tratamiento de la enfermedad de Cushing. Cirugía transesfenoidal y radioterapia hipofisaria. ACTA ACUST UNITED AC 2009; 56:123-31. [DOI: 10.1016/s1575-0922(09)70842-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 02/02/2009] [Indexed: 11/20/2022]
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Abstract
Growth-hormone hypersecretion, acromegaly, is associated with reduced life expectancy. First line treatment remains surgery, but remission rates vary between 50% and 90%. In case of lack of surgical remission or recurrence, somatostatin agonists can be proposed. However, about 30% of patients are partially or totally resistant to this treatment. The growth hormone receptor antagonist pegvisomant currently needs more prolonged follow-up studies. Conventional radiotherapy and radiosurgery are two radiation treatment modalities that can be proposed to these resistant patients. Reported rates of remission for conventional radiotherapy range between 50% and 60% in patients with acromegaly, with a time to remission delayed by several years, and adverse effects including high rates of hypopituitarism. This treatment could be proposed to patients with aggressive adenomas, in whom surgery cannot allow biochemical control. In contrast, studies on stereotactic radiosurgery reported lower rates of remission, with faster growth hormone hypersecretion decline, and a lower risk of adverse effects. However, this latter technique requires a well defined target volume, which limits its indications. The high precision of this technique makes it possible to be used as an alternative primary treatment to surgery. We reviewed major advantages and drawbacks of each of these techniques, based on recent studies to try to define their respective indications in the therapeutic algorithm of acromegaly.
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Affiliation(s)
- Frédéric Castinetti
- Department of Endocrinology, La Timone Hospital, Assistance Publique-Hôpitaux de Marseille and Université de la Mediterranée, Marseille, France
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Pituitary Tumors. Radiat Oncol 2008. [DOI: 10.1007/978-3-540-77385-6_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Castinetti F, Brue T. [Radiotherapy and radiosurgery of pituitary adenomas]. Presse Med 2008; 38:133-9. [PMID: 18954960 DOI: 10.1016/j.lpm.2008.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Accepted: 09/24/2008] [Indexed: 11/15/2022] Open
Abstract
There are two principal types of treatment for pituitary adenomas: fractionated conventional radiation therapy, based on biological selectivity, and radiosurgery, which is delivered in a single dose, based on anatomic selectivity and indicated preferentially for small tumors sufficiently distant from the optic chiasm. Conventional radiation therapy is effective against secretion in 60-80% of cases and radiosurgery in 40-50%, depending on the type of secretion. Maximum antisecretory efficacy is not reached immediately: this delay is longer for conventional radiation therapy (5-10 years) than for radiosurgery (2-3 years). In both cases, antisecretory treatment must be started, while awaiting remission. Radiation therapy and radiosurgery make it possible to stabilize or diminish tumor volume in 70-100% of cases. This is especially useful in the case of an active residue after surgery for non-secreting adenoma, but the long-term side effects of radiation must be borne in mind. The principal side effect is the onset of a pituitary deficiency (in more than 50% of cases after radiation therapy, 20% after radiosurgery). The risk increases with time since treatment. Other very long-term side effects have been described with radiation therapy: radiation-induced tumors, cerebral necrosis, strokes, etc. The role of radiosurgery and radiation therapy is growing ever more limited, because of the increasing efficacy of drug treatments and the excellent surgical results of experienced teams.
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Affiliation(s)
- Frédéric Castinetti
- Hôpital de la Timone et centre de référence des maladies rares d'origine hypophysaire, Assistance publique des hôpitaux de Marseille, Université de la Méditerranée, Marseille, France.
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Dekkers OM, Pereira AM, Romijn JA. Treatment and follow-up of clinically nonfunctioning pituitary macroadenomas. J Clin Endocrinol Metab 2008; 93:3717-26. [PMID: 18682516 DOI: 10.1210/jc.2008-0643] [Citation(s) in RCA: 173] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Although the majority of pituitary macroadenomas are clinically nonfunctioning, treatments as well as follow-up strategy for this condition lack evidence from randomized studies. EVIDENCE ACQUISITION We evaluated the evidence of treatment and follow-up strategies for clinically nonfunctioning adenomas. PubMed was searched for articles on nonfunctioning adenomas in November 2007, and references of selected articles were assessed for potentially relevant articles. EVIDENCE SYNTHESIS All evidence for treatment and follow-up for nonfunctioning adenomas is based on observational studies. The most effective treatment is transsphenoidal surgery, indicated in patients with visual field defects. A wait-and-see approach may be considered in nonfunctioning macroadenomas not reaching to the optic chiasm. Some of these tumors ( approximately 10%) will show spontaneous regression, whereas in approximately 50% there will be progression within 5 yr observation. Postoperative radiotherapy should not be applied to all patients after surgery but can be considered in patients with large postoperative remnants of the tumor. During follow-up careful assessment and replacement of pituitary insufficiencies should be performed. Magnetic resonance imaging is advised with intervals of 1-3 yr and evaluation of visual fields when appropriate. Recurrence rates are reported to be 6-46% after transsphenoidal surgery, whereas after postoperative radiotherapy, recurrence rates of 0-36% are reported. Long-term sequelae of nonfunctioning macroadenomas are hypopituitarism, persistent visual field defects, and decreased quality of life. Whether nonfunctioning macroadenomas are associated with an increased mortality is still a matter of debate. CONCLUSION Clinically nonfunctioning pituitary macroadenomas, although benign in nature, need individualized treatment and lifelong radiological and endocrinological follow-up.
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Affiliation(s)
- O M Dekkers
- Department of Endocrinology and Metabolic Diseases C4-R, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
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Roelfsema F, Biermasz NR, Pereira AM, Romijn JA. Therapeutic options in the management of acromegaly: focus on lanreotide Autogel. Biologics 2008; 2:463-79. [PMID: 19707377 PMCID: PMC2721386 DOI: 10.2147/btt.s3356] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In acromegaly, expert surgery is curative in only about 60% of patients. Postoperative radiation therapy is associated with a high incidence of hypopituitarism and its effect on growth hormone (GH) production is slow, so that adjuvant medical treatment becomes of importance in the management of many patients. OBJECTIVE To delineate the role of lanreotide in the treatment of acromegaly. METHODS Search of Medline, Embase, and Web of Science databases for clinical studies of lanreotide in acromegaly. RESULTS Treatment with lanreotide slow release and lanreotide Autogel((R)) normalized GH and insulin-like growth factor-I (IGF-I) concentrations in about 50% of patients. The efficacy of 120 mg lanreotide Autogel((R)) on GH and IGF-I levels was comparable with that of 20 mg octreotide LAR. There were no differences in improvement of cardiac function, decrease in pancreatic beta-cell function, or occurrence of side effects, including cholelithiasis, between octreotide LAR and lanreotide Autogel(R). When postoperative treatment with somatostatin analogs does not result in normalization of serum IGF-I and GH levels after noncurative surgery, pegvisomant alone or in combination with somatostatin analogs can control these levels in a substantial number of patients.
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Affiliation(s)
- Ferdinand Roelfsema
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke R Biermasz
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
| | - Alberto M Pereira
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
| | - Johannes A Romijn
- Department of Endocrinology and Metabolism, Leiden University Medical Center, Leiden, The Netherlands
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Bronstein MD. Long-term control of macroprolactinomas. Expert Rev Endocrinol Metab 2008; 3:361-376. [PMID: 30754204 DOI: 10.1586/17446651.3.3.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hyperprolactinemia is the most prevalent hypothalamic-pituitary dysfunction, with prolactinomas being its main cause. Microprolactinomas (diameter < 10 mm) represent approximately 60% of the prolactin-secreting adenomas, and are far more common in women than in men, whereas macroadenomas have roughly the same prevalence in both genders. The treatment of patients harboring macroprolactinomas is highly gratifying, with more than 80% of them adequately controlled by dopamine-agonist (DA) drugs: cabergoline being the most efficacious to date. Emerging evidence points to remission of the disease after long-term DA therapy in a significant number of patients. The remaining cases, mainly those with enclosed tumors, may be treated successfully by pituitary surgery. Radiotherapy is reserved for cases with dopaminergic drug resistance not surgically cured. The development of new therapeutic approaches may turn the control of the subset of macroprolactinomas refractory to both DA and surgery into reality.
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Affiliation(s)
- Marcello D Bronstein
- a Professor of Endocrinology, Chief, Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of Sao Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar 155-Predio dos Ambulatorios-8o andar-bloco3. CEP: 05403-900, Sao Paulo, SP, Brazil.
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Abstract
This article describes the technical aspects and the clinical results of conventional radiotherapy and modern stereotactic radiotherapy for pituitary adenomas. Systematic review of the published literature provides a factual basis for the comparison and the selection of appropriate radiation technique in patients who have secreting and nonfunctioning pituitary adenomas not cured with surgery and medical therapy.
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Affiliation(s)
- Michael Brada
- Academic Unit of Radiotherapy and Oncology, The Institute of Cancer Research, Downs Road, Sutton, Surrey SM2 5PT, UK.
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de Castro DG, Salvajoli JV, Canteras MM, Cecílio SAJ. [Radiosurgery for pituitary adenomas]. ACTA ACUST UNITED AC 2008; 50:996-1004. [PMID: 17221104 DOI: 10.1590/s0004-27302006000600004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2005] [Accepted: 06/08/2006] [Indexed: 11/22/2022]
Abstract
Pituitary adenomas represent nearly 15% of all intracranial tumors. Multimodal treatment includes microsurgery, medical management and radiotherapy. Microsurgery is the primary recommendation for nonfunctioning and most of functioning adenomas, except for prolactinomas that are usually managed with dopamine agonist drugs. However, about 30% of patients require additional treatment after microsurgery for recurrent or residual tumors. In these cases, fractionated radiation therapy has been the traditional treatment. More recently, radiosurgery has been established as a treatment option. Radiosurgery allows the delivery of prescribed dose with high precision strictly to the target and spares the surrounding tissues. Therefore, the risks of hypopituitarism, visual damage and vasculopathy are significantly lower. Furthermore, the latency of the radiation response after radiosurgery is substantially shorter than that of fractionated radiotherapy. The goal of this review is to define the efficacy, safety and role of radiosurgery for treatment of pituitary adenomas and to present the preliminary results of our institution.
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Castinetti F, Morange I, Jaquet P, Conte-Devolx B, Brue T. Ketoconazole revisited: a preoperative or postoperative treatment in Cushing's disease. Eur J Endocrinol 2008; 158:91-9. [PMID: 18166822 DOI: 10.1530/eje-07-0514] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT Although transsphenoidal surgery remains the first-line treatment in Cushing's disease (CD), recurrence is observed in about 20% of cases. Adjunctive treatments each have specific drawbacks. Despite its inhibitory effects on steroidogenesis, the antifungal drug ketoconazole was only evaluated in series with few patients and/or short-term follow-up. OBJECTIVE Analysis of long-term hormonal effects and tolerance of ketoconazole in CD. DESIGN A total of 38 patients were retrospectively studied with a mean follow-up of 23 months (6-72). SETTING All patients were treated at the same Department of Endocrinology in Marseille, France. PATIENTS The 38 patients with CD, of whom 17 had previous transsphenoidal surgery. INTERVENTION Ketoconazole was begun at 200-400 mg/day and titrated up to 1200 mg/day until biochemical remission. MAIN OUTCOME MEASURES Patients were considered controlled if 24-h urinary free cortisol was normalized. RESULTS Five patients stopped ketoconazole during the first week because of clinical or biological intolerance. On an intention to treat basis, 45% of the patients were controlled as were 51% of those treated long term. Initial hormonal levels were not statistically different between patients controlled or uncontrolled. Ketoconazole was similarly efficacious as a primary or postoperative treatment. Among 15 patients without visible adenoma at initial evaluation, subsequent follow-up allowed identification of the lesion in five cases. No adrenal insufficiency was observed. Adverse effects were rare in patients treated long term. CONCLUSIONS Ketoconazole is a safe and efficacious treatment in CD, particularly in patients for whom surgery is contraindicated, or delayed because of the absence of image of adenoma on magnetic resonance imaging.
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Affiliation(s)
- F Castinetti
- Department of Endocrinology, Diabetes, Metabolic Diseases and Nutrition, Hôpital de la Timone, Centre Hospitalier Universitaire de Marseille and Faculté de Médecine, Université de la Méditerranée, 264 rue St Pierre, Cedex 5, 13385 Marseille, France
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Minniti G, Brada M. Radiotherapy and radiosurgery for Cushing's disease. ACTA ACUST UNITED AC 2007; 51:1373-80. [DOI: 10.1590/s0004-27302007000800024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2007] [Accepted: 09/25/2007] [Indexed: 11/22/2022]
Abstract
Patients with residual or recurrent Cushing's disease receive external beam radiotherapy (RT) with the aim of achieving long-term tumour control and normalization of elevated hormone levels. Treatment is given either as conventional radiotherapy using conformal techniques or as stereotactic radiotherapy, which is either used as fractionated treatment (SCRT) or as single fraction radiosurgery (SRS). We describe the technical aspects of treatment and report a systematic review of the published literature on the efficacy and toxicity of conventional RT, SCRT and SRS. There are no studies directly comparing the different radiation techniques and the reported results are inevitably of selected patients by investigators with interest in the treatment tested. Nevertheless the review of the published literature suggests better hormone and tumour control rates after fractionated irradiation compared to single fraction radiosurgery. Hypopituitarism represents the most commonly reported late complication of radiotherapy seen after all treatments. Although the incidence of other late effects is low, the risk of radiation injury to normal neural structures is higher with single fraction compared to fractionated treatment. Stereotactic techniques offer more localized irradiation compared with conventional radiotherapy, however longer follow-up is necessary to confirm the potential reduction of long-term radiation toxicity of fractionated SCRT compared to conventional RT. On the basis of the available literature, fractionated conventional and stereotactic radiotherapy offer effective treatment for Cushing's disease not controlled with surgery alone. The lower efficacy and higher toxicity of single fraction treatment suggest that SRS is not the appropriate therapy for the majority of patients with Cushing's disease.
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Affiliation(s)
| | - Michael Brada
- the Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, UK
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Gilliot O, Khalil T, Irthum B, Zasadny X, Verrelle P, Tauveron I, Pontvert D. Radiotherapy of pituitary adenomas: state of the art. ANNALES D'ENDOCRINOLOGIE 2007; 68:337-48. [PMID: 17512895 DOI: 10.1016/j.ando.2007.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Revised: 02/26/2007] [Accepted: 03/13/2007] [Indexed: 11/26/2022]
Abstract
Pituitary adenomas represent approximately 12% of intracranial tumors. They are defined as tumors that are functional or nonfunctional and invasive or noninvasive. Therapeutic strategies rely on surgery, medical treatment, and radiotherapy depending on histology. Neither the role of external radiotherapy nor the technique to be used are firmly established. Nonfunctioning adenomas must be operated on to relieve the compression. Prolactin-secreting adenomas are first treated with dopamine agonists, and GH-secreting adenomas are first treated by surgery if excising the complete tumor is possible; otherwise medical treatment is started. The first-line treatment of ACTH-secreting adenomas is surgery; however, in many cases, insufficient control of either secretion or tumoral volume leads to consideration of irradiation. Complications of conventional radiotherapy are well known and fractionated stereotactic radiotherapy appears to be as safe as radiosurgery. The volume to irradiate is still difficult to define, and this parameter can influence the technique chosen for treatment. Because the indications of radiotherapy are still debated, irradiation of pituitary adenomas must be decided by the complete team of endocrinologists, neurosurgeons, radiologists and radiotherapists.
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Affiliation(s)
- O Gilliot
- Département d'oncologie-radiothérapie, centre Jean-Perrin, 58, rue Montalembert, BP 392, 63011 Clermont-Ferrand cedex 01, France.
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Kong DS, Lee JI, Lim DH, Kim KW, Shin HJ, Nam DH, Park K, Kim JH. The efficacy of fractionated radiotherapy and stereotactic radiosurgery for pituitary adenomas: long-term results of 125 consecutive patients treated in a single institution. Cancer 2007; 110:854-60. [PMID: 17599761 DOI: 10.1002/cncr.22860] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objective of this retrospective cohort study was to define the efficacy and safety of fractionated radiotherapy (FRT) and stereotactic radiosurgery (SRS) for the treatment of patients with pituitary adenoma. METHODS Between January 1995 and April 2006, 125 consecutive patients with pituitary adenomas (54 hormone-secreting adenomas and 71 nonsecretory adenomas) received FRT or underwent SRS. Sixty-four patients received FRT, for which the mean total dose was 50.4 grays (Gy) (range, 48-54 Gy), and 61 patients underwent gamma-knife SRS with mean marginal dose of 25.1 Gy (range, 9-30 Gy). RESULTS After mean follow up of 36.7 months, the tumor volume was increased in only 4 patients (3.2%). The overall actuarial progression-free survival rate was 99% at 2 years and 97% at 4 years. No difference was observed between the FRT group and the SRS group in the control of tumor growth. Based on the endocrinologic results in the patients who had secretory adenomas, the overall hormone complete remission rate was 26.2% at 2 years and 76.3% at 4 years. The median time to complete remission was 26 months in the SRS group and 63 months in the FRT group (P = .0068). Hypopituitarism developed as a delayed complication in 11.5% of patients at a median of 84 months. CONCLUSIONS Both FRT and SRS were efficient treatment modalities for the control of tumor growth in patients with pituitary adenomas. The current results indicated that single-dose radiosurgery more promptly produces an effect on the hypersecretion of pituitary hormones and may be recommended over FRT for suitable patients.
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Affiliation(s)
- Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Kangnam-Gu, Seoul, Korea
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Minniti G, Jaffrain-Rea ML, Osti M, Cantore G, Enrici RM. Radiotherapy for nonfunctioning pituitary adenomas: from conventional to modern stereotactic radiation techniques. Neurosurg Rev 2007; 30:167-75; discussion 175-6. [PMID: 17483973 DOI: 10.1007/s10143-007-0072-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2006] [Revised: 02/02/2007] [Accepted: 03/04/2007] [Indexed: 12/28/2022]
Abstract
The initial management of nonfunctioning pituitary macroadenomas (NFAs) is usually surgery; however, a significant proportion of NFAs may require further treatment. Radiotherapy is currently used in patients with residual tumour and achieves excellent long-term control, but there are concerns about potential late toxicity. Stereotactic radiotherapy, both in the form of radiosurgery or fractionated stereotactic radiotherapy, has been developed as a more accurate technique of irradiation with more precise tumour localization and consequently a reduction in the volume of normal tissue, particularly the brain, irradiated to high radiation doses. A review of the literature suggests that new radiation techniques offer safe and effective treatment for recurrent or residual pituitary adenomas; however longer follow-up is necessary to confirm the excellent tumour control and the potential reduction of long-term radiation toxicity. Currently, radiotherapy has an important role in patients with residual or progressive disease after surgery. Patients with small or no residual tumours after surgery may generally continue on a policy of surveillance without immediate irradiation, in order to avoid the potential toxicity of treatment.
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Affiliation(s)
- Giuseppe Minniti
- Department of Clinical Oncology, Neurooncology Unit, S Andrea Hospital, University La Sapienza, Rome, Italy.
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Minniti G, Osti M, Jaffrain-Rea ML, Esposito V, Cantore G, Maurizi Enrici R. Long-term follow-up results of postoperative radiation therapy for Cushing’s disease. J Neurooncol 2007; 84:79-84. [PMID: 17356896 DOI: 10.1007/s11060-007-9344-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2006] [Accepted: 01/26/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Radiotherapy is currently used in patients with residual or recurrent pituitary adenomas after surgery. However, there is little information of long-term outcome of patients with Cushing's disease following radiotherapy. We assessed the long-term efficacy and toxicity of conventional radiotherapy in the control of Cushing's disease after unsuccessful transsphenoidal surgery. PATIENTS AND METHODS Forty patients with Cushing's disease were treated with conventional external beam radiotherapy at our Institution between 1988 and 2002. The median age was 38. All patients received radiotherapy following unsuccessful surgery or at tumour recurrence to a dose of 45-50 Gy in 25-28 fractions. The persistence of active disease after surgery was diagnosed by the increased high plasma cortisol levels, high 24 h urinary cortisol levels and absence of cortisol suppression after administration of dexamethasone. RESULTS The 5 and 10 year local tumour control was 93% and the 5 and 10 year survival was 97 and 95%. Normalization of plasma cortisol was seen in 28% of patients at 1 year, 73% at 3 years, 78% at 5 years and 84% at 10 years. The average timing to remission was 24 months. The most common side effect was hypopituitarism that increased progressively during the follow-up, being present in 62% and in 76% of patients at 5 and 10 years after RT. There were no other serious complications as radiation induced optic neuropathy or second tumours. CONCLUSION Radiotherapy is effective in the long-term tumour- and hormone hypersecretion control of ACTH-secreting pituitary adenomas, however with a high prevalence of hypopituitarism. At the moment, it remains an important treatment option after failure of surgery.
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Affiliation(s)
- Giuseppe Minniti
- Department of Radiotherapy Oncology, Sant'Andrea Hospital, University of Rome La Sapienza, Via di Grottarossa 1035à, 00189, Rome, Italy.
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Neff LM, Weil M, Cole A, Hedges TR, Shucart W, Lawrence D, Zhu JJ, Tischler AS, Lechan RM. Temozolomide in the treatment of an invasive prolactinoma resistant to dopamine agonists. Pituitary 2007; 10:81-6. [PMID: 17285366 DOI: 10.1007/s11102-007-0014-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Prolactinomas are common tumors of the anterior pituitary gland. While conventional therapies, including dopamine agonists, transsphenoidal surgery and radiotherapy, are usually effective in controlling tumor growth, some patients develop treatment-resistant tumors. In this report, we describe a patient with an invasive prolactinoma resistant to conventional therapy that responded to the administration of the alkylating agent, temozolomide.
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Affiliation(s)
- Lisa M Neff
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Tufts-New England Medical Center, Boston, MA 02111, USA
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Castinetti F, Nagai M, Dufour H, Kuhn JM, Morange I, Jaquet P, Conte-Devolx B, Regis J, Brue T. Gamma knife radiosurgery is a successful adjunctive treatment in Cushing's disease. Eur J Endocrinol 2007; 156:91-8. [PMID: 17218730 DOI: 10.1530/eje.1.02323] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Though transsphenoidal surgery remains the first-line treatment of Cushing's disease, recurrence occurs frequently. Conventional radiotherapy and anticortisolic drugs both have adverse effects. Stereotactic radiosurgery needs to be evaluated more precisely. The aim of this study was to determine long-term hormonal effects and tolerance of gamma knife (GK) radiosurgery in Cushing's disease. DESIGN Forty patients with Cushing's disease treated by GK were prospectively studied over a decade, with a mean follow-up of 54.7 months. Eleven of them were treated with GK as a primary treatment. METHODS Radiosurgery was performed at the Department of Functional Neurosurgery of Marseille, France, using the Leksell Gamma Unit B and C models. Median margin dose was 29.5 Gy. Patients were considered in remission if they had normalized 24-h free urinary cortisol and suppression of plasma cortisol after low-dose dexamethasone suppression test. RESULTS Seventeen patients (42.5%) were in remission after a mean of 22 months (range 12-48 months). The two groups did not differ in terms of initial hormonal levels. Target volume was significantly higher in uncured than in remission group (909.8 vs 443 mm(3), P = 0.038). We found a significant difference between patients who were on or off anticortisolic drugs at the time of GK (20 vs 48% patients in remission respectively, P = 0.02). CONCLUSION With 42% of patients in remission after a median follow-up of 54 months, GK stereotactic radiosurgery, especially as an adjunctive treatment to surgery, may represent an alternative to other therapeutic options in view of their adverse effects.
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Affiliation(s)
- F Castinetti
- Federation of Endocrinology, Diabetes, Metabolic Diseases and Nutrition, Hôpital de la Timone, Centre Hospitalier Universitaire de Marseille and Faculté de Médecine, Université de la Méditerranée, 264 rue St Pierre, cedex 5, 13385 Marseille, France
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Olafsdottir A, Schlechte J. Management of resistant prolactinomas. ACTA ACUST UNITED AC 2006; 2:552-61. [PMID: 17024154 DOI: 10.1038/ncpendmet0290] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Accepted: 04/27/2006] [Indexed: 11/08/2022]
Abstract
Resistance to dopamine agonists occurs in a subset of patients with prolactin-secreting pituitary tumors. The resistance is mediated by loss of pituitary D2 receptors and occurs in both microadenomas and macroadenomas. Cabergoline is the most effective dopamine agonist and tumors that do not respond to bromocriptine or quinagolide frequently respond to cabergoline. Treatment options include maximizing the dose of the dopamine agonist, changing agonists, trans-sphenoidal surgery and radiation therapy. The goal of therapy is to restore and maintain gonadal and neurologic function, and this might occur in the absence of a normal prolactin level or a significant change in tumor size. Trans-sphenoidal pituitary surgery should be reserved for patients who are intolerant of medical therapy, or in whom this has failed. Radiation therapy has a limited role in treatment of resistant prolactinomas and should be reserved for patients in whom medical and surgical therapy has failed.
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Affiliation(s)
- Agusta Olafsdottir
- Division of Endocrinology and Metabolism, Department of Internal Medicine at the University of Iowa in Iowa City, IA 52242, USA
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