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Mathieu D, Kotecha R, Sahgal A, De Salles A, Fariselli L, Pollock BE, Levivier M, Ma L, Paddick I, Regis J, Yomo S, Suh JH, Rubens M, Sheehan JP. Stereotactic radiosurgery for secretory pituitary adenomas: systematic review and International Stereotactic Radiosurgery Society practice recommendations. J Neurosurg 2021; 136:801-812. [PMID: 34479203 DOI: 10.3171/2021.2.jns204440] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A systematic review was performed to provide objective evidence on the use of stereotactic radiosurgery (SRS) in the management of secretory pituitary adenomas and develop consensus recommendations. METHODS The authors performed a systematic review of the English-language literature up until June 2018 using the PRISMA guidelines. The PubMed (Medline), Embase, and Cochrane databases were searched. A total of 45 articles reporting single-institution outcomes of SRS for acromegaly, Cushing's disease, and prolactinomas were selected and included in the analysis. RESULTS For acromegaly, random effects meta-analysis estimates for crude tumor control rate, crude endocrine remission rate, and any new hypopituitarism rates were 97.0% (95% CI 96.0%-98.0%), 44.0% (95% CI 35.0%-53.0%), and 17.0% (95% CI 13.0%-23.0%), respectively. For Cushing's disease, random effects estimates for crude tumor control rate, crude endocrine remission rate, and any new hypopituitarism rate were 92.0% (95% CI 87.0%-95.0%), 48.0% (95% CI 35.0%-61.0%), and 21.0% (95% CI 13.0%-31.0%), respectively. For prolactinomas, random effects estimates for crude tumor control rate, crude endocrine remission rate, and any new hypopituitarism rate were 93.0% (95% CI 90.0%-95.0%), 28.0% (95% CI 19.0%-39.0%), and 12.0% (95% CI 6.0%-24.0%), respectively. Meta-regression analysis did not show a statistically significant association between mean margin dose with crude endocrine remission rate or mean margin dose with development of any new hypopituitarism rate for any of the secretory subtypes. CONCLUSIONS SRS offers effective tumor control of hormone-producing pituitary adenomas in the majority of patients but a lower rate of endocrine improvement or remission.
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Affiliation(s)
- David Mathieu
- 1Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Rupesh Kotecha
- 2Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Arjun Sahgal
- 3Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Antonio De Salles
- 4Department of Neurosurgery, University of California, Los Angeles, California
| | - Laura Fariselli
- 5Radiotherapy Unit-Neurosurgery Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Bruce E Pollock
- 6Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Marc Levivier
- 7Department of Neurosurgery and Gamma Knife Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Lijun Ma
- 8Department of Radiation Oncology, University of California, San Francisco, California
| | - Ian Paddick
- 9Medical Physics Ltd., Reading, United Kingdom
| | - Jean Regis
- 10Cromwell Hospital, London, United Kingdom.,11Functional and Stereotaxic Neurosurgery Department, Clinical Neuroscience Federation, La Timone Hospital, Aix-Marseille University, Marseille, France
| | - Shoji Yomo
- 12Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - John H Suh
- 13Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and
| | - Muni Rubens
- 2Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida
| | - Jason P Sheehan
- 14Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Abstract
External radiation therapy (RT) directed to the pituitary gland is generally recommended in patients with Cushing's disease (CD) as adjuvant to transsphenoidal surgery, among other second-line therapies offered to patients with residual or recurrent hypercortisolism (i.e., medical treatment, repeat surgery or bilateral adrenalectomy). RT is effective for the control of tumor growth, even in invasive tumors and in Nelson's syndrome. Progress in radiation stereotactic techniques lead to improved tumor targeting and radiation delivery, thus sparing the adjacent brain structures. Stereotactic RT is associated with a 55-65% rate of cortisol normalization after several months to a few years and potentially with a lower risk of long-term complications, compared with conventional RT. Cortisol-lowering medical therapy is recommended while awaiting the radiation effects. Hypopituitarism is the most frequent side-effect, damage to optic or cranial nerves or second brain tumors are rarely reported. This review presents the updates in the efficacy and safety of the stereotactic radiation techniques in CD patients. Practical points which should be considered by the clinician before recommending RT are also presented.
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Affiliation(s)
- Monica Livia Gheorghiu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; National Institute of Endocrinology C.I. Parhon, Bucharest, Romania.
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3
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Bunevicius A, Kano H, Lee CC, Krsek M, Nabeel AM, El-Shehaby A, Abdel Karim K, Martinez-Moreno N, Mathieu D, Lee JYK, Grills I, Kondziolka D, Martinez-Alvarez R, Reda WA, Liscak R, Su YH, Lunsford LD, Lee Vance M, Sheehan JP. Early versus late Gamma Knife radiosurgery for Cushing's disease after prior resection: results of an international, multicenter study. J Neurosurg 2021; 134:807-815. [PMID: 32084634 DOI: 10.3171/2019.12.jns192836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 12/13/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The optimal time to perform stereotactic radiosurgery after incomplete resection of adrenocorticotropic hormone (ACTH)-producing pituitary adenoma in patients with Cushing's disease (CD) remains unclear. In patients with persistent CD after resection of ACTH-producing pituitary adenoma, the authors evaluated the association of the interval between resection and Gamma Knife radiosurgery (GKRS) with outcomes. METHODS Pooled data from 10 institutions participating in the International Radiosurgery Research Foundation were used in this study. RESULTS Data from 255 patients with a mean follow-up of 65.59 ± 49.01 months (mean ± SD) were analyzed. Seventy-seven patients (30%) underwent GKRS within 3 months; 46 (18%) from 4 to 6 months; 34 (13%) from 7 to 12 months; and 98 (38%) at > 12 months after the resection. Actuarial endocrine remission rates were higher in patients who underwent GKRS ≤ 3 months than when treatment was > 3 months after the resection (78% and 65%, respectively; p = 0.017). Endocrine remission rates were lower in patients who underwent GKRS at > 12 months versus ≤ 12 months after the resection (57% vs 76%, respectively; p = 0.006). In multivariate Cox regression analyses adjusted for clinical and treatment characteristics, early GKRS was associated with increased probability of endocrine remission (hazard ratio [HR] 1.518, 95% CI 1.039-2.218; p = 0.031), whereas late GKRS (HR 0.641, 95% CI 0.448-0.919; p = 0.015) was associated with reduced probability of endocrine remission. The incidence of some degree of new pituitary deficiency (p = 0.922), new visual deficits (p = 0.740), and other cranial nerve deficits (p = 0.610) was not significantly related to time from resection to GKRS. CONCLUSIONS Early GKRS is associated with an improved endocrine remission rate, whereas later GKRS is associated with a lower rate of endocrine remission after pituitary adenoma resection. Early GKRS should be considered for patients with CD after incomplete pituitary adenoma resection.
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Affiliation(s)
- Adomas Bunevicius
- 1Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hideyuki Kano
- 2Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Cheng-Chia Lee
- 3Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Michal Krsek
- 4Third Department of Internal Medicine, First Faculty of Medicine of the Charles University and General Teaching Hospital, Prague, Czech Republic
| | - Ahmed M Nabeel
- 5Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Benha University, Benha, Egypt
| | - Amr El-Shehaby
- 6Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt
| | - Khaled Abdel Karim
- 7Clinical Oncology Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt
| | - Nuria Martinez-Moreno
- 8Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - David Mathieu
- 9Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - John Y K Lee
- 10Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Inga Grills
- 11Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan
| | - Douglas Kondziolka
- 12Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Roberto Martinez-Alvarez
- 8Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, Madrid, Spain
| | - Wael A Reda
- 6Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt
| | - Roman Liscak
- 13Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic; and
| | - Yan-Hua Su
- 3Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - L Dade Lunsford
- 2Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Lee Vance
- 1Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia
- 14Department of Medicine, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- 1Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia
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Capatina C, Hinojosa-Amaya JM, Poiana C, Fleseriu M. Management of patients with persistent or recurrent Cushing's disease after initial pituitary surgery. Expert Rev Endocrinol Metab 2020; 15:321-339. [PMID: 32813595 DOI: 10.1080/17446651.2020.1802243] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/24/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Treatment options for persistent and recurrent Cushing's disease (CD) include an individualized approach for repeat surgery, medical treatment, radiation therapy (RT), and bilateral adrenalectomy (BLA). AREAS COVERED In this expert opinion perspective, the authors review the latest treatment(s) for persistent/recurrent CD. A PubMed search was undertaken (English articles through May 2020) and relevant articles discussed. Repeat pituitary surgery should be considered in most patients with proven hypercortisolism; there is potential for cure with low risk of major complications. Medical therapy is valuable either alone, while awaiting the effects of RT, or in preparation for BLA. Medical therapy includes steroidogenesis inhibitors, agents that act at the pituitary or glucocorticoid receptor level, and novel agents in development. Radiation therapy has been used successfully to treat CD, but hypopituitarism risk and delayed efficacy (improved with radiosurgery) are major drawbacks. Laparoscopic BLA is safe and effective in patients with severe, difficult-to-manage hypercortisolism, but long-term follow-up is required as corticotroph tumor progression can develop. EXPERT OPINION Treatment of persistent/recurrent CD is challenging. Most patients require >1 therapy to achieve long-lasting remission. There is currently no ideal single treatment option that provides high and rapid efficacy, low adverse effects, and preserves normal pituitary-adrenal axis function.
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Affiliation(s)
- Cristina Capatina
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, C.I. Parhon National Institute of Endocrinology , Bucharest, Romania
| | - José Miguel Hinojosa-Amaya
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University , Portland, Oregon, USA
- Endocrinology Division, Department of Medicine, Hospital Universitario Dr. José E. González, Universidad Autónoma De Nuevo León , Monterrey, Nuevo León, Mexico
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, C.I. Parhon National Institute of Endocrinology , Bucharest, Romania
| | - Maria Fleseriu
- Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Oregon Health & Science University , Portland, Oregon, USA
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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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6
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Surgical and radiosurgical treatment strategies for Cushing’s disease. J Neurooncol 2019; 145:403-413. [DOI: 10.1007/s11060-019-03325-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 10/26/2019] [Indexed: 12/11/2022]
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7
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Shrivastava A, Mohammed N, Xu Z, Liščák R, Kosak M, Krsek M, Karim KA, Lee CC, Martínez-Moreno N, Lee Vance M, Lunsford LD, Sheehan JP. Outcomes After Gamma Knife Stereotactic Radiosurgery in Pediatric Patients with Cushing Disease or Acromegaly: A Multi-Institutional Study. World Neurosurg 2019; 125:e1104-e1113. [PMID: 30790739 DOI: 10.1016/j.wneu.2019.01.252] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/24/2019] [Accepted: 01/25/2019] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Pituitary adenomas comprise about 3% of all intracranial tumors in pediatric patients. This study examines the role of stereotactic radiosurgery in the management of pediatric acromegaly or patients with Cushing disease (CD). METHODS From an international consortium, we retrospectively collected treatment and outcome data on pediatric adrenocorticotrophic hormone and growth hormone-secreting pituitary adenomas treated with Gamma Knife radiosurgery (GKRS). There were a total of 36 patients including 24 with CD and 12 with acromegaly. The data were analyzed to assess outcomes including tumor control, endocrine remission, and adverse effects. Statistical analysis was performed to determine correlation between clinical/treatment parameters and outcomes. RESULTS At the last follow-up after GKRS, endocrine remission rates for CD and acromegaly were 80% and 42%, respectively. Tumor control was achieved in 87.5% of patients with CD and in 42% of patients with acromegaly. New pituitary hormone deficiency occurred in 7 of the 36 patients at a median time of 18 months after GKRS (range, 12-81 months). The predictive factors for endocrine remission were age <15 years (P = 0.015) and margin dose (P = 0.042). The median endocrine follow-up was 63.7 months (range, 7-246 months). CONCLUSIONS GKRS affords reasonable rates of endocrine remission and tumor control in most pediatric patients with functioning adenomas. The most common post-GKRS complication was hypopituitarism, although this occurred in only a few patients. Given the larger at-risk period for pediatric patients, further study is required to evaluate for delayed recurrences and hypopituitarism.
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Affiliation(s)
- Adesh Shrivastava
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Nasser Mohammed
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Zhiyuan Xu
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Roman Liščák
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, USA
| | - Mikulas Kosak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, USA
| | - Michal Krsek
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, USA
| | | | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veteran General Hospital, Taiwan, USA
| | - Nuria Martínez-Moreno
- Department of Neurological Surgery and Gamma Knife Radiosurgery, Ruber International Hospital, Madrid, USA
| | - Mary Lee Vance
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia, USA
| | - L Dade Lunsford
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.
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Ironside N, Chen CJ, Lee CC, Trifiletti DM, Vance ML, Sheehan JP. Outcomes of Pituitary Radiation for Cushing's Disease. Endocrinol Metab Clin North Am 2018; 47:349-365. [PMID: 29754636 DOI: 10.1016/j.ecl.2018.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Achievement of biochemical remission with preservation of normal pituitary function is the goal of treatment for Cushing's disease. For patients with persistent or recurrent Cushing's disease after transsphenoidal resection, radiation therapy may be a safe and effective treatment. Stereotactic radiosurgery is favored over conventional fractionated external beam radiation. Hormonal recurrence rates range from 0% to 36% at 8 years after treatment. Tumor control rates are high. New pituitary hormone deficiency is the most common adverse effect after stereotactic radiosurgery and external beam radiation. The effects of radiation planning optimization and use of adjuvant medication on endocrine remission rates warrant investigation.
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Affiliation(s)
- Natasha Ironside
- Department of Neurosurgery, Auckland City Hospital, Private Bag 92 024, Auckland Mail Center, Auckland 1142, New Zealand
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, PO Box 800-212, Charlottesville, VA 22908, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, 17 Floor, No. 201, Sec. 2, Shipai Road, Beitou District, Taipei 11217, Taiwan
| | - Daniel M Trifiletti
- Department of Radiation Oncology, Mayo Clinic, 4500 San Pablo Road South, Jacksonville, FL 32224, USA
| | - Mary Lee Vance
- Division of Endocrinology and Metabolism, University of Virginia Health System, 2 Floor, Suite 2100, 415 Ray C Hunt Drive, Charlottesville, VA 22908, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, PO Box 800-212, Charlottesville, VA 22908, USA.
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Moore JM, Sala E, Amorin A, Martinez H, Bhowmik AC, Chang SD, Soltys SG, Harsh GR, Katznelson L. CyberKnife Radiosurgery in the Multimodal Management of Patients with Cushing Disease. World Neurosurg 2018; 112:e425-e430. [DOI: 10.1016/j.wneu.2018.01.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 10/18/2022]
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Minniti G, Osti MF, Niyazi M. Target delineation and optimal radiosurgical dose for pituitary tumors. Radiat Oncol 2016; 11:135. [PMID: 27729088 PMCID: PMC5057503 DOI: 10.1186/s13014-016-0710-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 10/01/2016] [Indexed: 11/10/2022] Open
Abstract
Stereotactic radiosurgery (SRS) delivered as either single-fraction or multi-fraction SRS (2–5 fractions) is frequently employed in patients with residual or recurrent pituitary adenoma. The most common delivery systems used for SRS include the cobalt-60 system Gamma Knife, the CyberKnife (CK) robotic radiosurgery system, or a modified conventional radiotherapy machine (linear accelerator, LINAC). Tumor control and normalization of hormone hypersecretion have been reported in 75–100 % and 25–80 % of patients, respectively. Hypopituitarism is the most commonly reported late complication of radiation treatment, whereas other toxicities occur less frequently. We have provided an overview of the recent available literature on SRS in patients with a pituitary adenoma. Critical aspects of pituitary irradiation, including target delineation and doses to organs at risk, optimal radiation dose, as well as the long-term efficacy and toxicity of SRS for either nonfunctioning or secreting pituitary adenomas are discussed. Single-fraction SRS represents an effective treatment for patients with a pituitary adenoma; however, caution should be used for lesions > 2.5–3 cm in size and/or involving the anterior optic pathway. Future studies will be necessary to optimize target doses and critical organ dose constrains in order to reduce the long-term toxicity of treatments while maintaining high efficacy.
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Affiliation(s)
- Giuseppe Minniti
- Unit of Radiation Oncology, Sant' Andrea Hospital, University Sapienza, Rome, Italy. .,IRCCS Neuromed, Pozzilli (IS), Italy.
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Abstract
After transsphenoidal surgery, Cushing's disease (CD) shows excellent long-term remission rates, but it may recur and pose a therapeutic challenge. Findings in recent published reports on the treatment of recurrent adrenocorticotropic hormone (ACTH)-secreting tumors suggest that repeat resection, radiation-based therapies such as Gamma Knife surgery and proton-beam radiosurgery, pharmacotherapy, and bilateral adrenalectomy all have important roles in the treatment of recurrent CD. Each of these interventions has inherent risks and benefits that should be presented to the patient during counseling on retreatment options. Radiation-based therapies increasingly appear to have efficacies similar to those of repeat resection in achieving biochemical remission and tumor control. In addition, an expanding retinue of medication-based therapies, several of which are currently being evaluated in clinical trials, has shown some promise as tertiary adjunctive therapies. Lastly, bilateral adrenalectomy may offer durable control of refractory recurrent CD. An increasing number of published studies with long-term patient outcomes highlight the evolving treatment patterns in the management of recurrent CD.
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12
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Pivonello R, De Leo M, Cozzolino A, Colao A. The Treatment of Cushing's Disease. Endocr Rev 2015; 36:385-486. [PMID: 26067718 PMCID: PMC4523083 DOI: 10.1210/er.2013-1048] [Citation(s) in RCA: 297] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 05/13/2015] [Indexed: 12/23/2022]
Abstract
Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Monica De Leo
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Alessia Cozzolino
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
| | - Annamaria Colao
- Dipartimento Di Medicina Clinica E Chirurgia, Sezione Di Endocrinologia, Universita' Federico II di Napoli, 80131 Naples, Italy
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13
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Minniti G, Clarke E, Scaringi C, Enrici RM. Stereotactic radiotherapy and radiosurgery for non-functioning and secreting pituitary adenomas. Rep Pract Oncol Radiother 2014; 21:370-8. [PMID: 27330422 DOI: 10.1016/j.rpor.2014.09.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/28/2014] [Accepted: 09/16/2014] [Indexed: 11/18/2022] Open
Abstract
Radiotherapy (RT) is frequently employed in patients with residual or recurrent pituitary adenoma with excellent rates of tumor control and remission of hormonal hypersecretion. Advances in RT have improved with the use of stereotactic techniques either as fractionated stereotactic radiotherapy (FSRT) or stereotactic radiosurgery (SRS), all aiming to improve the dose distribution to the tumor while reducing the amount of normal brain receiving significant doses of radiation. We provide an overview of the recent published literature on the long-term efficacy and adverse effects of stereotactic irradiation in nonfunctioning and secreting pituitary adenomas. Both techniques are associated with excellent clinical outcomes; however, advantages and drawbacks of each of these techniques in terms of local control, hormonal excess normalization, and radiation-induced toxicity remain a matter of debate. In clinical practice, single-fraction SRS may represent a convenient approach to patients with small and medium-sized pituitary adenoma away at least 2 mm from the optic chiasm, whereas FSRT is preferred over SRS for lesions >2.5-3 cm in size and/or involving the anterior optic pathway.
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Affiliation(s)
- Giuseppe Minniti
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy
| | - Enrico Clarke
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Claudia Scaringi
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Riccardo Maurizi Enrici
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
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Sheehan JP, Yen CP, Lee CC, Loeffler JS. Cranial stereotactic radiosurgery: current status of the initial paradigm shifter. J Clin Oncol 2014; 32:2836-46. [PMID: 25113762 PMCID: PMC4152711 DOI: 10.1200/jco.2013.53.7365] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The concept of stereotactic radiosurgery (SRS) was first described by Lars Leksell in 1951. It was proposed as a noninvasive alternative to open neurosurgical approaches to manage a variety of conditions. In the following decades, SRS emerged as a unique discipline involving a collegial partnership among neurosurgeons, radiation oncologists, and medical physicists. SRS relies on the precisely guided delivery of high-dose ionizing radiation to an intracranial target. The focused convergence of multiple beams yields a potent therapeutic effect on the target and a steep dose fall-off to surrounding structures, thereby minimizing the risk of collateral damage. SRS is typically administered in a single session but can be given in as many as five sessions or fractions. By providing an ablative effect noninvasively, SRS has altered the treatment paradigms for benign and malignant intracranial tumors, functional disorders, and vascular malformations. Literature on extensive intracranial radiosurgery has unequivocally demonstrated the favorable benefit-to-risk profile that SRS affords for appropriately selected patients. In a departure from conventional radiotherapeutic strategies, radiosurgical principles have recently been extended to extracranial indications such as lung, spine, and liver tumors. The paradigm shift resulting from radiosurgery continues to alter the landscape of related fields.
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Affiliation(s)
- Jason P Sheehan
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Chun-Po Yen
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Cheng-Chia Lee
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jay S Loeffler
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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15
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Unyielding progress: recent advances in the treatment of central nervous system neoplasms with radiosurgery and radiation therapy. J Neurooncol 2014; 119:513-29. [PMID: 25119001 DOI: 10.1007/s11060-014-1501-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
Abstract
In the past decade, our understanding of the roles of external beam radiotherapy (EBRT) and stereotactic radiosurgery (SRS) in the management of brain tumors has dramatically improved. To highlight the changes and contemporary treatment approaches, we review the indications and outcomes of ionizing radiation for benign intracranial tumors and brain metastases. For nonfunctioning pituitary adenomas, SRS is able to achieve radiographic tumor control in at least 90 % of cases. The rate of SRS-induced endocrine remission for functioning pituitary adenomas depends on the tumor subtype, but it is generally lower than the rate of radiographic tumor control. The most common complications from pituitary adenoma SRS treatment are hypopituitarism and cranial neuropathies. SRS has become the preferred treatment modality for vestibular schwannomas and skull base meningiomas less than 3 cm in size. Large vestibular schwannomas and meningiomas remain best managed with initial surgical resection or EBRT for surgically ineligible patients. For small to moderately sized brain metastases, there has been a shift toward treatment of newly diagnosed patients with SRS alone due to similar local control rates compared with surgical resection. RCTs have shown combined SRS and whole brain radiation therapy (WBRT) for brain metastases to decrease rates of local and distant intracranial recurrence compared to SRS alone. However, the improved intracranial control comes at the expense of poorer neurocognitive outcomes and without prolonging overall survival. Therefore, WBRT is generally reserved for salvage therapy. While EBRT has been frequently supplanted by SRS for the treatment pituitary adenomas and brain metastases, it still proves useful in selected cases of large lesions which are not amenable to surgical debulking or for those with widespread disease, poor performance status, and short life expectancy. In recent years, the scope of SRS has extended beyond the intracranial space to include extradural and intradural spinal tumors.
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Wilson P, Williams J, Smee R. Cushing’s disease: A single centre’s experience using the linear accelerator (LINAC) for stereotactic radiosurgery and fractionated stereotactic radiotherapy. J Clin Neurosci 2014; 21:100-6. [DOI: 10.1016/j.jocn.2013.04.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 04/17/2013] [Accepted: 04/19/2013] [Indexed: 10/26/2022]
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17
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Ding D, Starke RM, Sheehan JP. Treatment paradigms for pituitary adenomas: defining the roles of radiosurgery and radiation therapy. J Neurooncol 2013; 117:445-57. [DOI: 10.1007/s11060-013-1262-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 09/22/2013] [Indexed: 12/25/2022]
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