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Li L, Ding G, Zhang L, Luo H, Davoodi-Bojd E, Li Q, Chopp M, Zhang ZG, Jiang Q. Glymphatic transport is reduced in rats with spontaneous pituitary tumor. Front Med (Lausanne) 2023; 10:1189614. [PMID: 37601793 PMCID: PMC10436560 DOI: 10.3389/fmed.2023.1189614] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background and objective Pituitary tumor in patients induces adverse alterations in the brain, accompanied by cognitive deficits. Dysfunction of glymphatic waste clearance results in accumulation of neurotoxic products within the brain, leading to cognitive impairment. However, the status of glymphatic function in the brain with pituitary tumor is unknown. Using magnetic resonance imaging (MRI) and an advanced mathematical modeling, we investigated the changes of glymphatic transport in the rats carrying spontaneous pituitary tumor. Methods Rats (22-24 months, female, Wistar) with and without pituitary tumor (n = 7/per group) underwent the identical experimental protocol. MRI measurements, including T2-weighted imaging and dynamic 3D T1-weighted imaging with intracisternal administration of contrast agent, were performed on each animal. The contrast-induced enhancement in the circle of Willis and in the glymphatic influx nodes were observed on the dynamic images and verified with time-signal-curves (TSCs). Model-derived parameters of infusion rate and clearance rate that characterize the kinetics of glymphatic tracer transport were evaluated in multiple representative brain regions. Results Our imaging data demonstrated a higher incidence of partially enhanced circle of Willis (86 vs. 14%; p < 0.033) and a lower incidence of enhancement in glymphatic influx nodes of pituitary (71 vs. 100%) and pineal (57 vs. 86%) recesses in the rats with pituitary tumor than in the rats with normal appearance of pituitary gland, indicating an intensification of impaired peri-vascular pathway and impeded glymphatic transport due to the presence of pituitary tumor. Consistently, our kinetic modeling and regional cerebral tissue quantification revealed significantly lower infusion and clearance rates in all examined regions in rats with spontaneous pituitary tumor than in non-tumor rats, representing a suppressed glymphatic transport in the brain with pituitary tumor. Conclusion Our study demonstrates the compromised glymphatic transport in the rat brain with spontaneous pituitary tumor. The reduced efficiency in cerebral waste clearance increases the risk for neurodegeneration in the brain that may underlie the cognitive impairment commonly seen in patients with pituitary tumors.
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Affiliation(s)
- Lian Li
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | - Guangliang Ding
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | - Li Zhang
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | - Hao Luo
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | | | - Qingjiang Li
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | - Michael Chopp
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
- Department of Physics, Oakland University, Rochester, MI, United States
| | - Zheng Gang Zhang
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
| | - Quan Jiang
- Department of Neurology, Henry Ford Health, Detroit, MI, United States
- Department of Physics, Oakland University, Rochester, MI, United States
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Cognitive Dysfunction, an Increasingly Valued Long-Term Impairment in Acromegaly. J Clin Med 2023; 12:jcm12062283. [PMID: 36983284 PMCID: PMC10058029 DOI: 10.3390/jcm12062283] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/26/2023] [Accepted: 03/08/2023] [Indexed: 03/17/2023] Open
Abstract
Acromegaly is a chronic disease caused by the overproduction of growth hormone (GH) and accompanying insulin-like growth factor-1 (IGF-1), which is often caused by GH-secreting pituitary adenomas. In addition to its somatic burden, a growing number of studies have found that patients suffering from acromegaly exhibit psychosocial and personality changes. Over the past 70 years, there has been increasing interest in the cognitive impairment and neuropsychological issues of patients with acromegaly, and a variety of neuropsychological and neurophysiological tests have been used to measure cognitive changes in patients. The impact of disease progression status, treatment modalities, and various comorbidities on cognitive function and the mechanisms of cognitive impairment in patients with acromegaly are therefore outlined in this review. Multidisciplinary assessment has important implications for the management of acromegaly, particularly in relation to cognitive function. Here, we summarize the relevant literature concerning cognitive-behavioral research on acromegaly to demonstrate the impact of long-term impairment caused by GH and IGF-1 on the cognitive behavior of patients.
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Hyperprolactinemia Associated with Attentional Processing and Interference Control Impairments in Patients with Prolactinomas. Brain Sci 2022; 12:brainsci12081091. [PMID: 36009154 PMCID: PMC9406026 DOI: 10.3390/brainsci12081091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 11/25/2022] Open
Abstract
The cognitive impairment of pituitary adenomas (PAs) has received increasing attention. Hyperprolactinemia and tumor mass effect are the potential causes. The aim of this study was to identify possible cognitive impairment and to further explore the correlation between these indices and prolactin (PRL) levels, based on the control of tumor size. Twenty-seven patients with prolactinomas (patient group) and twenty-six matched health control group (HC group) were enrolled in this study. All participants performed the flanker task while we continuously recorded electroencephalography data. On the behavioral performance level, patients showed a significantly slower reaction time (RT) in both flanker types. Concerning the event-related potentials level, patients elicited reduced P2 and enhanced N2 amplitudes compared with the HC group, suggesting an impairment of attentional processing (P2) and conflict monitoring (N2). Moreover, the patient group also induced lower P3 amplitudes relative to the HC group in both types, indicating that there were deficits in attentional resource allocation ability. We also found a significant correlation between the P3 amplitudes and incongruent condition RTs, as well as the subsequent PRL levels in the patient group. In conclusion, this is an innovative study that reveals the impaired cognition abilities in prolactinomas, and also proposes the possible cognitive toxicity of oversecreted PRL levels, which provides evidence for further research on the cognitive decline in PAs.
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Gorelyshev S, Savateev AN, Mazerkina N, Medvedeva O, Konovalov AN. Craniopharyngiomas: Surgery and Radiotherapy. Adv Tech Stand Neurosurg 2022; 45:97-137. [PMID: 35976448 DOI: 10.1007/978-3-030-99166-1_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Taking into account the benign nature of craniopharyngiomas, the main method of treatment is the resection of the tumor. However, the tendency of these tumors to invade critical structures (such as optic pathways, the hypothalamic-pituitary system, the Willis circle vessels) often limits the possibility of a radical surgery.Craniopharyngiomas of the third ventricle represent the greatest challenge for surgery. After radical surgery, hypothalamic disorders often occur, including not only obesity but also cognitive, emotional, mental, and metabolic disturbances. Metabolic disorders associated with damage to the hypothalamus progress after surgery and lead to impaired functions of the internal organs. This process is irreversible and, in many cases, becomes the direct cause of mortality. The life expectancy of patients with the surgically affected hypothalamus is significantly shorter than in patients with preserved diencephalic function. The incidence of hypothalamic disorders after surgery can reach 40%.Even with macroscopically total resection, craniopharyngiomas can recur in 10-30% of cases, and in the presence of tumor remnants and with no further radiation treatment, the risk of recurrence significantly increases to up to 50-85% according to various studies. For this reason, the observation of patients with residual tumors after surgery is an incorrect strategy.Radiation therapy significantly improves progression-free survival (PFS), and the use of stereotactic irradiation techniques ensures conformity of irradiation of tumor remnants with a complicated shape and location (Iwata H et al., J Neurooncol 106(3):571-577, 2012; Aggarwal et al., Pituitary 16(1):26-33, 2013; Savateev et al., Zh Vopr Neirokhir Im N N Burdenko 81(3):94-106; 2017), which potentially reduces the risk of undesirable postradiation effects. Therefore, the quality of life in patients with craniopharyngiomas infiltrating the hypothalamus is significantly higher after non-radical operations with subsequent stereotactic radiation than after a total or subtotal removal.
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Affiliation(s)
- Sergey Gorelyshev
- Federal State Autonomous Institution (N. N. Burdenko National Medical Research Center of Neurosurgery) of the Ministry of Health of the Russian Federation, Moscow, Russia.
| | | | - Nadezhda Mazerkina
- Federal State Autonomous Institution (N. N. Burdenko National Medical Research Center of Neurosurgery) of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Olga Medvedeva
- Federal State Autonomous Institution (N. N. Burdenko National Medical Research Center of Neurosurgery) of the Ministry of Health of the Russian Federation, Moscow, Russia
| | - Alexander N Konovalov
- Federal State Autonomous Institution (N. N. Burdenko National Medical Research Center of Neurosurgery) of the Ministry of Health of the Russian Federation, Moscow, Russia
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Early experience with hippocampal avoidance whole brain radiation therapy and simultaneous integrated boost for brain metastases. J Neurooncol 2020; 148:81-88. [PMID: 32307637 DOI: 10.1007/s11060-020-03491-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/08/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Cranial irradiation results in cognitive decline, which is hypothesized to be partially attributable to hippocampal injury and stem cell loss. Recent advances allow for targeted reduction of radiation dose to the hippocampi while maintaining adequate dose coverage to the brain parenchyma and additional increasing dose to brain metastases, a approach called hippocampal avoidance whole brain radiation therapy with a simultaneous integrated boost (HA-WBRT + SIB.) We review our early clinical experience with HA-WBRT + SIB. MATERIALS AND METHODS We evaluated treatments and clinical outcomes for patients treated with HA-WBRT + SIB between 2014 and 2018. RESULTS A total of 32 patients (median age, 63.5 years, range 45.3-78.8 years) completed HA-WBRT + SIB. Median follow-up for patients alive at the time of analysis was 11.3 months. The most common histology was non-small cell lung cancer (n = 22). Most patients (n = 25) were prescribed with WBRT dose of 30 Gy with SIB to 37.5 Gy in 15 fractions. Volumetric modulated arc therapy reduced treatment time (p < 0.0001). Median freedom from intracranial progression and overall survival from completion of treatment were 11.4 months and 19.6 months, respectively. Karnofsky Performance Status was associated with improved survival (p = 0.008). The most common toxicities were alopecia, fatigue, and nausea. Five patients developed cognitive impairment, including grade 1 (n = 3), grade 2 (n = 1), and grade 3 (n = 1). CONCLUSION HA-WBRT + SIB demonstrated durable intracranial disease control with modest side effects and merits further investigation as a means of WBRT toxicity reduction while improving long-term locoregional control in the brain.
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Marsh L, Guinan E, Shah E, Powell M, Lowy C, Kopelman MD. A prospective study of the cognitive and psychiatric effects of pituitary tumours and their treatments. J Clin Neurosci 2020; 75:122-127. [PMID: 32199742 DOI: 10.1016/j.jocn.2020.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 01/16/2020] [Accepted: 03/08/2020] [Indexed: 11/15/2022]
Abstract
Neurocognitive complaints are common in patients with pituitary tumours, particularly in memory and concentration. Past studies have shown impairments in executive function and memory, but it is not clear whether these result from direct effects of the tumour (pressure or hormonal secretion), incidental damage from radiotherapy or surgical treatments, and/or mediating psychiatric factors. This study assessed cognitive function and psychiatric state of 86 pituitary tumour patients and 18 healthy controls, pre and post-treatment, to examine the effects of tumour aetiology and treatment type. No significant cognitive impairments were found, except on verbal recognition memory. Patients with Cushing's disease showed lower verbal recognition memory than the other groups pre-treatment, but improved at follow-up. This was (at least partially) accounted for by an improvement in depression scores. Patients who were treated with surgery showed poorer verbal recognition memory than controls across all (pre- and post-treatment) time-points. Overall findings of minimal cognitive impairment in patients with pituitary tumours may reflect improved diagnostic and treatment techniques in recent years. We suggest that the verbal memory impairments identified in the Cushing's group may result from increased cortisol (directly, or mediated by depression). In the surgical groups, verbal memory impairments appeared to pre-date treatment. This may relate to treatment selection factors, rather than harmful effects of surgery itself.
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Affiliation(s)
- Laura Marsh
- King's College London, Based at St Thomas's Hospital, London SE1 7EH, United Kingdom
| | - Elizabeth Guinan
- King's College London, Based at St Thomas's Hospital, London SE1 7EH, United Kingdom
| | - Emily Shah
- King's College London, Based at St Thomas's Hospital, London SE1 7EH, United Kingdom
| | - Michael Powell
- National Hospital for Neurology and Neurosurgery, London WC1, United Kingdom
| | - Clara Lowy
- King's College London, Based at St Thomas's Hospital, London SE1 7EH, United Kingdom; Guy's and St Thomas's NHS Foundation Trust, United Kingdom
| | - Michael D Kopelman
- King's College London, Based at St Thomas's Hospital, London SE1 7EH, United Kingdom
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7
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Zarino B, Verrua E, Ferrante E, Sala E, Carosi G, Giavoli C, Serban AL, Del Sindaco G, Sirtori MA, Bertani GA, Rampini P, Carrabba GG, Arosio M, Spada A, Locatelli M, Mantovani G. Cushing's disease: a prospective case-control study of health-related quality of life and cognitive status before and after surgery. J Neurosurg 2019; 133:1721-1731. [PMID: 31731265 DOI: 10.3171/2019.8.jns19930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 08/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Some studies have highlighted psychological and neuropsychological difficulties and a potential reduction in health-related quality of life (HRQOL) in patients with pituitary tumors, despite hormone deficits or excess. To the authors' knowledge, this study is the first prospective longitudinal case-control study with the aim of simultaneously testing whether HRQOL and psychiatric and neuropsychological disabilities are related to neural dysfunction due to hypercortisolism per se, or tumor mass and/or surgery in patients with Cushing's disease (CD). The authors evaluated a homogeneous cohort of patients with CD and nonfunctioning pituitary adenomas (NFPAs) before and after neurosurgery and compared these patients with healthy controls. METHODS Twenty patients (10 with NFPA and 10 with CD) were evaluated using 3 validated questionnaires (SF-36, Beck Depression Inventory-II [BDI-II], and Minnesota Multiphasic Personality Inventory-II [MMPI-II]) to assess HRQOL and psychological status preoperatively and 12 months after neurosurgery. Neuropsychological tests were assessed preoperatively, 3-7 days postoperatively, and 12 months postoperatively. Twenty healthy matched controls were recruited. RESULTS Preoperatively, the NFPA and CD subgroups had worse HRQOL scores than controls on the basis of SF-36 scores, although the NFPA subgroup experienced significant recovery 12 months postoperatively. Preoperatively, CD patients had depressive symptoms according to the BDI-II and MMPI-II that persisted 12 months postoperatively, together with social introversion and hypochondriasis; NFPA patients were similar to controls except for hypochondriasis scores that were clinically significant at all timepoints. Preoperatively and 3-7 days postoperatively, both subgroups showed significant neuropsychological disabilities compared with controls, but only the CD subgroup did not completely recover over time. CONCLUSIONS HRQOL and neuropsychological impairments were observed in all patients at early timepoints, independent of hypercortisolism, tumor mass, and successful surgery. Over time, CD patients showed persistent changes in HRQOL, in particular in social activities. In this light, CD seems to have a strong impact on HRQOL and to be associated with more psychological and neuropsychological comorbidities than NFPA.
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Affiliation(s)
| | - Elisa Verrua
- 2Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | - Emanuele Ferrante
- 2Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | - Elisa Sala
- 2Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | - Giulia Carosi
- 2Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
- Departments of3Clinical Sciences and Community Health, and
| | - Claudia Giavoli
- 2Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
- Departments of3Clinical Sciences and Community Health, and
| | - Andreea L Serban
- 2Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
- 6Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - Giulia Del Sindaco
- 2Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
- Departments of3Clinical Sciences and Community Health, and
| | - Martina A Sirtori
- 1Neurosurgery Unit and
- 5Department of Psychology, University of Milano-Bicocca, Milan; and
| | | | | | | | - Maura Arosio
- 2Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
- Departments of3Clinical Sciences and Community Health, and
| | - Anna Spada
- Departments of3Clinical Sciences and Community Health, and
| | - Marco Locatelli
- 1Neurosurgery Unit and
- 4Pathophysiology and Transplantation, University of Milan
| | - Giovanna Mantovani
- 2Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
- Departments of3Clinical Sciences and Community Health, and
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8
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Tooze A, Sheehan JP. Neurocognitive changes in pituitary adenoma patients after Gamma Knife radiosurgery. J Neurosurg 2019; 129:55-62. [PMID: 30544290 DOI: 10.3171/2018.7.gks181595] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPituitary adenomas and the treatment required for the underlying neuropathology have frequently been associated with cognitive dysfunction. However, the mechanisms for these impairments remain the subject of much debate. The authors evaluated cognitive outcomes in patients treated with or without Gamma Knife radiosurgery (GKRS) for an underlying pituitary adenoma.METHODSThis was a retrospective, institutional review board-approved, single-institution study. A total of 51 patients (23 male, 28 female) treated for pituitary adenoma were included in this neurocognitive study. Twenty-one patients underwent GKRS following transsphenoidal surgery, 22 patients were treated with transsphenoidal surgery alone, and eight patients were conservatively managed or were treated with medical management alone. Comparisons using psychometric tests of general intellectual abilities, memory, and executive functions were made between the treatment groups, between male and female patients, and between patients with Cushing's disease and those with nonfunctioning adenoma (NFA).RESULTSThe entire patient sample, the NFA group, and the GKRS group scored significantly below expected on measures of both immediate and delayed memory, particularly for visually presented information (p ≤ 0.05); however, there were no significant differences between the patients with Cushing's disease and those with NFA (t ≤ 0.56, p ≥ 0.52). In those who underwent GKRS, memory scores were not significantly different from those in the patients who did not undergo GKRS (t ≤ 1.32, p ≥ 0.19). Male patients across the sample were more likely to demonstrate impairments in both immediate memory (t = -3.41, p = 0.003) and delayed memory (t = -3.80, p = 0.001) than were female patients (t ≤ 1.09, p ≥ 0.29). There were no impairments on measures of general intellectual functioning or executive functions in any patient group. The potential contributions of tumor size and hormone levels are discussed.CONCLUSIONSOverall, pituitary adenoma patients demonstrated relative impairment in anterograde memory. However, GKRS did not lead to adverse effects for immediate or delayed memory in pituitary adenoma patients. Cognitive assessment of pituitary adenoma patients is important in their longitudinal care.
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Affiliation(s)
- Alana Tooze
- 1Sussex Rehabilitation Centre, Princess Royal Hospital, Haywards Heath, Sussex, United Kingdom; and
| | - Jason P Sheehan
- 2Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Butterbrod E, Gehring K, Voormolen EH, Depauw PRAM, Nieuwlaat WA, Rutten GJM, Sitskoorn MM. Cognitive functioning in patients with nonfunctioning pituitary adenoma before and after endoscopic endonasal transsphenoidal surgery. J Neurosurg 2019; 133:709-716. [PMID: 31443073 DOI: 10.3171/2019.5.jns19595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 05/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Patients with nonfunctioning pituitary adenomas (NFPAs) can suffer from cognitive dysfunction. However, the literature on longitudinal cognitive follow-up of patients undergoing endoscopic endonasal transsphenoidal surgery (EETS) is limited. This study was performed to investigate perioperative cognitive status and course in patients with NFPAs. METHODS Patients underwent computerized neuropsychological assessment 1 day before (n = 45) and 3 months after (n = 36) EETS. Performance in 7 domains was measured with a computerized test battery (CNS Vital Signs) and standardized using data from a healthy control group. The authors conducted analyses of cognitive performance at both time points and changes pre- to post-ETSS on a group and an individual level. Linear multiple regression analyses were employed to investigate predictors of cognitive performance. RESULTS On average, patients scored significantly lower in 6 of 7 cognitive domains before and after surgery than controls. Impairment proportions were significantly higher among patients (56% before surgery, 63% after surgery) than among controls. Patients showed no change over time in group-level (mean) performance, but 28% of individual patients exhibited cognitive improvement and 28% exhibited cognitive decline after surgery. Hormonal deficiency showed a positive correlation with verbal memory before surgery. Postoperative performances in all cognitive domains were predicted by preoperative performances. CONCLUSIONS Cognitive impairment was present before and after EETS in over half of NFPA patients. Individual patients showed diverse postoperative cognitive courses. Monitoring of cognitive functioning in clinical trajectories and further identification of disease-related and psychological predictors of cognition are warranted.
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Affiliation(s)
- Elke Butterbrod
- 1Department of Cognitive Neuropsychology, Tilburg University; and
| | - Karin Gehring
- 1Department of Cognitive Neuropsychology, Tilburg University; and
- 2Departments of Neurosurgery and
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10
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Pertichetti M, Serioli S, Belotti F, Mattavelli D, Schreiber A, Cappelli C, Padovani A, Gasparotti R, Nicolai P, Fontanella MM, Doglietto F. Pituitary adenomas and neuropsychological status: a systematic literature review. Neurosurg Rev 2019; 43:1065-1078. [DOI: 10.1007/s10143-019-01134-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/16/2019] [Accepted: 06/10/2019] [Indexed: 12/16/2022]
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11
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Kan W, Wang R, Yang K, Liu H, Zou Y, Liu Y, Zhao J, Luo Z, Chen J. Effect of Hormone Levels and Aging on Cognitive Function of Patients with Pituitary Adenomas Prior to Medical Treatment. World Neurosurg 2019; 128:e252-e260. [PMID: 31026659 DOI: 10.1016/j.wneu.2019.04.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 04/13/2019] [Accepted: 04/15/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cognitive impairments have been reported in patients with pituitary adenomas (PAs). The aim of this research was to demonstrate the effects of hormones and age on cognitive decline in patients with PAs. METHODS A total of 64 patients with PA and 69 healthy control subjects (HCs) were recruited for this study. Both PAs and HCs were divided into a younger group (<50 years of age) and an older group (≥50 years of age). Neurocognitive domains were assessed using the Wechsler Adult Intelligence Scale-Chinese Revision (WAIS-RC) and Wechsler Memory Scale-Chinese Revision (WMS-RC) tests. Furthermore, we also investigated the relationship between cognitive domains and tumor volume, and the hormone levels and age of patients with PA. RESULTS Several of the cognitive impairments found on the WAIS-RC and WMS-RC tests were more frequently observed in untreated patients with PA. Importantly, no significant correlations were found between cognitive domains and tumor volume after controlling age, sex, and educational levels. Furthermore, several significant correlations were found between cognitive domains and hormone levels, such as free thyroxine and adrenocorticotropic hormone, after controlling age, sex, and educational levels. Finally, the age of the patients was found to correlate with a decrease in memory after controlling sex and educational levels. CONCLUSIONS Our findings demonstrate a significant decline in the cognitive performance of patients with PA prior to medical treatment, especially in older patients, which suggests that hormones and age have the ability to interact and aggravate cognitive decline in patients with PA.
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Affiliation(s)
- Wenwu Kan
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Ran Wang
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Kun Yang
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China; Institute of Brain Functional Imaging, Nanjing Medical University, Nanjing, Jiangsu, China.
| | - Hongyi Liu
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yuanjie Zou
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yong Liu
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jinbing Zhao
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Zhengxiang Luo
- Department of Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jiu Chen
- Institute of Brain Functional Imaging, Nanjing Medical University, Nanjing, Jiangsu, China; Institute of Neuropsychiatry, The Affiliated Brain Hospital of Nanjing Medical University, Fourth Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
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12
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Cognitive function surrounding resection of nonfunctioning pituitary adenomas with suprasellar extension: A prospective matched-control study. J Clin Neurosci 2017; 40:109-114. [DOI: 10.1016/j.jocn.2017.02.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 02/10/2017] [Indexed: 11/20/2022]
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13
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The impact on cognitive functions of patients with pituitary adenoma before and after surgery. Neurol Sci 2017; 38:1315-1321. [DOI: 10.1007/s10072-017-2980-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 04/26/2017] [Indexed: 12/19/2022]
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14
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Savateev AN, Trunin YY, Mazerkina NA. [Radiotherapy and radiosurgery in treatment of craniopharyngiomas]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2017; 81:94-106. [PMID: 28665393 DOI: 10.17116/neiro201781394-106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Craniopharyngiomas are benign epithelial tumors having a dysembryogenetic origin, which are usually located in the sellar/parasellar and/or third ventricle regions. Gross total resection is the modern standard of treatment for these tumors because of a low recurrence rate. However, this surgery in some patients with craniopharyngioma often leads to the development or worsening of diencephalic disorders poorly responding to treatment. Perhaps, in these cases, subtotal or partial tumor resection or implantation of an Ommaya reservoir into the tumor cyst followed by stereotactic radiotherapy/radiosurgery may provide better functional outcomes and higher life quality in patients, with tumor growth control being reasonable (according to the published data, the mean 10-year disease-free survival is 66.9% after total tumor resection and 79.6% after combined treatment). The paper presents a review of the literature on radiological treatment of craniopharyngiomas. We discuss the issues of indications, optimal timing of radiotherapy/radiosurgery, its efficacy, and treatment outcomes in terms of complications and quality of life. Particular attention is paid to enlargement of craniopharyngioma cysts during and after radiological treatment.
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Affiliation(s)
- A N Savateev
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - Yu Yu Trunin
- Burdenko Neurosurgical Institute, Moscow, Russia
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Wang S, Zheng D, Zhang C, Ma R, Bennion NR, Lei Y, Zhu X, Enke CA, Zhou S. Automatic planning on hippocampal avoidance whole-brain radiotherapy. Med Dosim 2017; 42:63-68. [DOI: 10.1016/j.meddos.2016.12.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 11/22/2016] [Accepted: 12/05/2016] [Indexed: 10/20/2022]
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Chang JS, Perez-Andujar A, Barani IJ, Ma L, Larson DA. Estimating the probability of underdosing microscopic brain metastases with hippocampal-sparing whole-brain radiation. Radiother Oncol 2016; 120:248-52. [DOI: 10.1016/j.radonc.2016.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 05/20/2016] [Accepted: 05/22/2016] [Indexed: 10/21/2022]
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Chang JS, Ma L, Barani IJ, McDermott MW, Sneed PK, Larson DA. Hippocampal Dose With Radiosurgery for Multiple Intracranial Targets. Technol Cancer Res Treat 2016; 15:555-9. [DOI: 10.1177/1533034615590934] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 04/29/2015] [Indexed: 11/15/2022] Open
Abstract
Stereotactic radiosurgery provides conformal treatment of intracranial lesions, but when multiple lesions are treated, cumulative dose to structures such as the hippocampi may be increased. We analyzed hippocampal dose for patients treated with radiosurgery for multiple brain metastases. We then investigated a means to minimize hippocampal dose. We randomly selected 8 patients treated with single-session, frame-based radiosurgery for 6 to 12 intracranial metastases. Standard planning was employed to deliver 16 to 20 Gy to each lesion without hippocampal avoidance. Each case was replanned using the software’s dynamic shaping function to minimize direct beam hippocampal irradiation, while maintaining conformality and target coverage. With standard planning, the maximum hippocampal dose varied from 0.8 to 9.0 Gy but was >3 Gy only when a lesion was <10 mm from the hippocampus. There was no clear correlation between hippocampal dose and the number or the total volume of lesions. Replanning with direct beam avoidance decreased the mean hippocampal dose by an average of 35% but increased treatment time by a mean of 20%. Sparing was most pronounced when the closest lesion was in close proximity to the hippocampus. This is the first study reporting hippocampal dose for multilesion intracranial radiosurgery. It illustrates that when multiple intracranial targets are treated with radiosurgery, substantial hippocampal dose can result. Active beam shielding and optimization can lower hippocampal dose, especially with lesions <10 mm from the hippocampus. These results raise the prospect that the risk of neurocognitive side effects may be further decreased with a hippocampal-sparing approach.
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Affiliation(s)
- Jennifer S. Chang
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Lijun Ma
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - Igor J. Barani
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | | | - Penny K. Sneed
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
| | - David A. Larson
- Department of Radiation Oncology, University of California, San Francisco, CA, USA
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The Influences of Whole Brain Radiotherapy on Social Cognition and Association with Hippocampal and Frontal Dosimetry. Psychiatr Q 2015; 86:533-43. [PMID: 25687977 DOI: 10.1007/s11126-015-9349-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The influence of brain radiotherapy on neurocognition is a major concern. Social cognition is a mental process in the meaning of social interaction and the recognition of facial emotion is a domain of social cognition. Thus, we aimed to investigate the early effect of whole brain radiotherapy on facial emotion recognition ability. Thirteen patients with various brain tumors in the study. Beck depression and anxiety inventory and the facial emotion recognition test by using a set of photographs were performed at the beginning and post radiotherapy. The severity of depression (16.40 ± 12.16 vs 04.00 ± 02.38 points) and anxiety (14.47 ± 11.96 vs 04.54 ± 03.30 points) were significantly higher in patients. The only significance according to facial emotion recognition rate between initial phase of patients and healthy controls was identifying neutral facial em otion (p = 0.002). The patients after brain radiotherapy had significantly better rate of recognizing fear facial emotions (p = 0.039). This study is the first that investigated the effects of cranial irradiation on facial emotion recognition ability and compares this ability with healthy controls. Interestingly, in the early phase the patients seem to be improved in fear facial emotion after brain radiotherapy without sparing cognition specific regions as hippocampus and frontal regions.
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Lecumberri B, Estrada J, García-Uría J, Millán I, Pallardo LF, Caballero L, Lucas T. Neurocognitive long-term impact of two-field conventional radiotherapy in adult patients with operated pituitary adenomas. Pituitary 2015; 18:782-95. [PMID: 25820377 DOI: 10.1007/s11102-015-0653-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
PURPOSE To assess the long-term impact of postoperative two-field-conventional radiotherapy (RT) on neurocognitive functions of adult patients with operated pituitary adenomas (PA). METHODS We selected 124 adult patients with operated PA-56 of whom had also received RT-recorded their main clinical data and performed a neuropsychological assessment in all of them that included 15 standardized tests, and a cerebral SPECT in eight patients. Comparative analyses were carried out on major clinical and neurocognitive domains between irradiated and not irradiated patients, and on cerebral SPECT source. RESULTS Compared with non-irradiated patients, irradiated patients performed significantly worse on Barcelona's story recall test (P < 0.001) and arithmetic problems (P < 0.03) and on five categories of the Wisconsin card sorting test, especially on perseverative answers and errors (P < 0.001) without differences in other examined functional domains. RT was the only factor associated with worse results in these tests regardless other clinical and treatment-related variables. Kaplan-Meier analysis suggested that the probability of achieving poorer results with time was related to RT total dose and field-size, type of PA and age at the time of RT. Four of the five SPECTS performed in irradiated patients revealed a similar altered perfusion in the left temporal lobe cortical region. CONCLUSIONS In adult patients with operated PA, RT was independently associated with an impairment on verbal memory and executive function, when compared to non-irradiated patients. Our data suggest that diagnosis of acromegaly or Cushing's disease, and age at the time of RT were able to modulate this long-term radio-induced neurocognitive sequelae.
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Affiliation(s)
- Beatriz Lecumberri
- Endocrinology and Nutrition Department, La Paz University Hospital, Castellana 261, 28046, Madrid, Spain.
- Endocrinology and Nutrition Department, Puerta de Hierro University Hospital, Madrid, Spain.
| | - Javier Estrada
- Endocrinology and Nutrition Department, Puerta de Hierro University Hospital, Madrid, Spain
| | - José García-Uría
- Neurosurgery Department, Puerta de Hierro University Hospital, Madrid, Spain
| | - Isabel Millán
- Statistics Department, Puerta de Hierro University Hospital, Madrid, Spain
| | - Luis Felipe Pallardo
- Endocrinology and Nutrition Department, La Paz University Hospital, Castellana 261, 28046, Madrid, Spain
| | - Luis Caballero
- Psychiatry Department, Puerta de Hierro University Hospital, Madrid, Spain
| | - Tomás Lucas
- Endocrinology and Nutrition Department, Puerta de Hierro University Hospital, Madrid, Spain
- Sanchinarro University Hospital, Madrid, Spain
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Tomé WA, Gökhan Ş, Gulinello ME, Brodin NP, Heard J, Mehler MF, Guha C. Hippocampal-dependent neurocognitive impairment following cranial irradiation observed in pre-clinical models: current knowledge and possible future directions. Br J Radiol 2015; 89:20150762. [PMID: 26514377 DOI: 10.1259/bjr.20150762] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We reviewed the literature for studies pertaining to impaired adult neurogenesis leading to neurocognitive impairment following cranial irradiation in rodent models. This compendium was compared with respect to radiation dose, converted to equivalent dose in 2 Gy fractions (EQD2) to allow for direct comparison between studies. The effects of differences between animal species and the dependence on animal age as well as for time after irradiation were also considered. One of the major sites of de novo adult neurogenesis is the hippocampus, and as such, this review also focuses on assessing evidence related to the expression and potential effects of inflammatory cytokines on neural stem cells in the subgranular zone of the dentate gyrus and whether this correlates with neurocognitive impairment. This review also discusses potential strategies to mitigate the detrimental effects on neurogenesis and neurocognition resulting from cranial irradiation, and how the rationale for these strategies compares with the current outcome of pre-clinical studies.
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Affiliation(s)
- Wolfgang A Tomé
- 1 Institute for Onco-Physics, Department of Radiation Oncology, Albert Einstein College of Medicine, Bronx, NY, USA.,2 Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA.,3 Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Şölen Gökhan
- 3 Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maria E Gulinello
- 4 Department of Neuroscience, Albert Einstein College of Medicine, Bronx, NY, USA
| | - N Patrik Brodin
- 1 Institute for Onco-Physics, Department of Radiation Oncology, Albert Einstein College of Medicine, Bronx, NY, USA.,2 Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA
| | - John Heard
- 2 Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA
| | - Mark F Mehler
- 3 Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA.,4 Department of Neuroscience, Albert Einstein College of Medicine, Bronx, NY, USA.,5 Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Chandan Guha
- 1 Institute for Onco-Physics, Department of Radiation Oncology, Albert Einstein College of Medicine, Bronx, NY, USA.,2 Department of Radiation Oncology, Montefiore Medical Center, Bronx, NY, USA
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Estabrook NC, McDonald MW, Hoene TA, Bartlett GK, Johnstone PA, McMullen KP, Buchsbaum JC. Proton Radiotherapy for Midline Central Nervous System Lesions: A Class Solution. Oncology 2015; 89:111-7. [DOI: 10.1159/000377727] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 02/05/2015] [Indexed: 11/19/2022]
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Chowdhury T, Prabhakar H, Bithal PK, Schaller B, Dash HH. Early cognitive decline in pituitary surgery: is nitrous oxide the culprit? FUTURE NEUROLOGY 2014. [DOI: 10.2217/fnl.14.45] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Aim: Pituitary tumors have been found to produce cognitive dysfunctions predominantly related to memory and attention. There exists a potential interaction between surgical and anesthetic factors in producing cognitive changes. Therefore we aim to investigate the incidence of cognitive decline and role of nitrous oxide (N2O) on immediate cognitive changes in patients undergoing transsphenoidal removal of pituitary tumors. Patients & methods: Ninety patients between 18 and 65 years of age, undergoing transsphenoidal surgery for pituitary tumor removal, were enrolled and divided into two (air and N2O-based anesthetic regime) groups. Cognitive functions were noted using the Hindi Mini Mental State Examination at baseline and three times in the postoperative period (1-h, 24-h postextubation and at the time of hospital discharge). Results: Both groups were comparable with respect to demographics, baseline parameters and cognitive scores. Significant number of patients (73%) showed cognitive decline in both the groups within 24 h postoperatively. In the factor analysis, thyroid-stimulating hormone and fentanyl consumption were linked with changes in cognitive scores. Conclusion: Patients undergoing pituitary surgery have significantly immediate cognitive decline in the short followup, but N2O-based anesthesia alone does not increase the risk of postoperative cognitive decline.
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Affiliation(s)
- Tumul Chowdhury
- Department of Anesthesia & Perioperative Medicine, 2nd Floor, Herry Medovy House, 671 - William's Ave, Health Sciences Center, University of Manitoba, Winnipeg, R3E 0Z2, Canada
| | - Hemanshu Prabhakar
- Department of Neuroanesthesiology & Neuro-Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Parmod K Bithal
- Department of Neuroanesthesiology & Neuro-Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Bernhard Schaller
- Department of Research, University of Southampton, University Road, Southampton, SO17 1BJ, UK
| | - Hari H Dash
- Department of Anesthesiology & Critical Care, Fortis Memorial Research Institute, Gurgaon, India
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Pinkham MB, Bertrand KC, Olson S, Zarate D, Oram J, Pullar A, Foote MC. Hippocampal-sparing radiotherapy: the new standard of care for World Health Organization grade II and III gliomas? J Clin Neurosci 2013; 21:86-90. [PMID: 24090519 DOI: 10.1016/j.jocn.2013.04.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 03/31/2013] [Accepted: 04/07/2013] [Indexed: 01/18/2023]
Abstract
The neurocognitive effects of cranial radiotherapy in patients with gliomas are well-recognised and may be related to the dose delivered to the hippocampi. Intensity modulated radiotherapy (IMRT) is a radiotherapy technique that can be used to selectively spare the hippocampi without compromising the dose delivered to the tumour. This study aimed to evaluate if hippocampal-sparing IMRT is achievable in patients with World Health Organization (WHO) grade II and III gliomas. A retrospective review of consecutive patients with WHO grade II and III gliomas treated with IMRT at our institution between January 2009 and August 2012 was performed. Hippocampal-sparing was defined as a mean dose to at least one hippocampus of less than 30 Gy. The dose delivered to the tumour was never compromised to achieve the hippocampal dose constraint. Logistic regression analyses were performed to identify predictive factors for achieving hippocampal-sparing treatment. Eighteen patients were identified and hippocampal-sparing was achieved in 14 (78%). The median dose prescribed was 59.4 Gy in 33 fractions and 11 patients had WHO grade III gliomas. The mean dose to the contralateral hippocampus was 24.9 Gy. Planning target volumes less than 420.5 cm3 were more likely to enable hippocampal-sparing treatment to be given (hazard ratio 1.7, p=0.03) and there was a trend with oligodendrogliomas and anaplastic oligodendrogliomas. Hippocampal-sparing radiotherapy is feasible in patients with WHO grade II and III gliomas. Oncologic outcomes are yet to be assessed prospectively. The relationship between hippocampal dose and neurocognitive function in adults is currently under investigation.
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Affiliation(s)
- M B Pinkham
- Department of Radiation Oncology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102, Australia; University of Queensland, Brisbane, QLD, Australia.
| | - K C Bertrand
- University of Queensland, Brisbane, QLD, Australia
| | - S Olson
- Department of Neurosurgery, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - D Zarate
- Consultant, statistics and data analysis, Brisbane, QLD, Australia
| | - J Oram
- Department of Neurosurgery, Princess Alexandra Hospital, Woolloongabba, QLD, Australia; Department of Neuropsychology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - A Pullar
- Department of Radiation Oncology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102, Australia; University of Queensland, Brisbane, QLD, Australia
| | - M C Foote
- Department of Radiation Oncology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, QLD 4102, Australia; Diamantina Institute, University of Queensland, Brisbane, QLD, Australia; University of Queensland, Brisbane, QLD, Australia
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Abstract
Radiotherapy remains the mainstay of multidisciplinary management of patients with incompletely resected and recurrent craniopharyngioma. Advances in imaging and radiotherapy technology offer new alternatives with the principal aim of improving the accuracy of treatment and reducing the volume of normal brain receiving significant radiation doses. We review the available technologies, their technical advantages and disadvantages and the published clinical results. Fractionated high precision conformal radiotherapy with image guidance remains the gold standard; the results of single fraction treatment are disappointing and hypofractionation should be used with caution as long term results are not available. There is insufficient data on the use of protons to assess the comparative efficacy and toxicity. The precision of treatment delivery needs to be coupled with experienced infrastructure and more intensive quality assurance to ensure best treatment outcome and this should be carried out within multidisciplinary teams experienced in the management of craniopharyngioma. The advantages of the combined skills and expertise of the team members may outweigh the largely undefined clinical gain from novel radiotherapy technologies.
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Capatina C, Christodoulides C, Fernandez A, Cudlip S, Grossman AB, Wass JAH, Karavitaki N. Current treatment protocols can offer a normal or near-normal quality of life in the majority of patients with non-functioning pituitary adenomas. Clin Endocrinol (Oxf) 2013; 78:86-93. [PMID: 22640418 DOI: 10.1111/j.1365-2265.2012.04449.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 05/02/2012] [Accepted: 05/23/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Non-functioning pituitary adenomas (NFA) may be associated with significant morbidity. Published data on the quality of life (QoL) of patients with NFA are scarce and conflicting. In view of the discordant findings and the advances in the management of these subjects, we aimed to evaluate the QoL in patients with NFA followed up in a tertiary endocrine UK referral centre. SUBJECTS AND METHODS All consecutive patients with NFA attending the outpatient clinic in the Department of Endocrinology in Oxford over a 6-month period (n = 193) were offered 3 health-related QoL questionnaires [Short Form 36 (SF36), Nottingham Health Profile (NHP), European Quality of Life Scale (EuroQoL)] to complete. Patient outcomes (response rate 93.3%) were compared with age-related UK reference values. RESULTS None of the QoL scores in the SF-36 or the 5 dimensions of health in the EuroQoL was different from the reference values. The visual analogue scale (VAS) score (EuroQoL) was slightly compromised (P = 0.041). In the NHP questionnaire, males had no parameter significantly affected, whereas females performed worse in 1/6 areas (energy levels). Tumour recurrence was an independent predictor for compromised VAS score and for anxiety/depression (EuroQoL), and visual field defects for more frequent problems with interests/hobbies (NHP). CONCLUSIONS Overall, the health-related QoL and perception of subjective health in patients with NFA was not compromised to any major extent suggesting that we can now offer the prospect of treatment and replacement, which will provide a normal or near-normal QoL. Specific groups are affected in various dimensions, necessitating measures to compensate for predisposing factors.
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Affiliation(s)
- Cristina Capatina
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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Neurocognitive Changes in Pituitary Adenoma Patients After Fractionated External Beam Radiotherapy Versus Gamma Knife Radiosurgery. World Neurosurg 2012; 78:53-7. [DOI: 10.1016/j.wneu.2011.12.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 12/09/2011] [Indexed: 11/21/2022]
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Tooze A, Hiles CL, Sheehan JP. Neurocognitive Changes in Pituitary Adenoma Patients After Gamma Knife Radiosurgery: A Preliminary Study. World Neurosurg 2012; 78:122-8. [DOI: 10.1016/j.wneu.2011.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 09/03/2011] [Indexed: 11/24/2022]
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Sheplan Olsen LJ, Robles Irizarry L, Chao ST, Weil RJ, Hamrahian AH, Hatipoglu B, Suh JH. Radiotherapy for prolactin-secreting pituitary tumors. Pituitary 2012; 15:135-45. [PMID: 21948464 DOI: 10.1007/s11102-011-0348-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Review the medical and surgical management of patients with prolactinomas and provide an in-depth appraisal of the role of radiotherapy in the treatment of prolactinomas. A thorough review of the pertinent literature was carried out and relevant topics were identified. Topics covered in this comprehensive review include: indications for the use of radiotherapy, choice between conventional radiotherapy and stereotactic radiosurgery, as well as the benefits and potential complications associated with each modality. Due to the excellent response rates with medical management, and rapid symptom relief afforded by resection or debulking surgery in patients who do not respond or tolerate medical therapy, radiotherapy is reserved for patients who do not respond to dopamine agonists and surgery. Both external beam radiotherapy and stereotactic radiosurgery retain important roles in the treatment of refractory or recurrent prolactinomas. Choosing the optimal approach is crucial in maximizing tumor control outcomes and minimizing the risks associated with treatment. The primary determinants of optimal radiation approach are proximity of the tumor to the optic apparatus and tumor size, with radiosurgery being our recommended treatment of choice unless the tumor is larger than 3-4 cm or within 3 mm of the optic nerves, chiasm or tracts. Optimal multidisciplinary management requires the identification of appropriate candidates for radiotherapy in order to take full advantage of treatment options available for each patient.
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Psaras T, Milian M, Hattermann V, Gerlach C, Honegger J. Executive functions recover earlier than episodic memory after microsurgical transsphenoidal resection of pituitary tumors in adult patients--a longitudinal study. J Clin Neurosci 2011; 18:1340-5. [PMID: 21782447 DOI: 10.1016/j.jocn.2011.01.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2010] [Revised: 01/08/2011] [Accepted: 01/16/2011] [Indexed: 11/16/2022]
Abstract
Pituitary tumors may lead to cognitive dysfunction, and the most prevalent deficits are impaired memory and attention. To investigate whether memory and executive functions improve after surgical treatment we performed a prospective longitudinal study comprising 106 patients with pituitary tumors. Psychometric evaluation was performed with the d2-Letter Cancellation test, the Trail Making test, the Digit Span test and the Intelligence Structure test-Verbal Memory test at three timepoints: preoperatively, and at 3 months and 12 months after surgery. The preoperative and postoperative maximum suprasellar tumor extension and hormone status was assessed in all participants. The main finding was that concentration, working memory, and attentional speed improved significantly within the first 3 months after surgery (p<0.05), while improvement of episodic memory was not observed until 12 months after surgery (p<0.001). In the patients harbouring non-functioning adenomas, prolactinomas or other sellar lesions, the most important factor promoting improvement of neurocognitive function was the removal of the suprasellar tumor extension.
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Affiliation(s)
- T Psaras
- Department of Neurosurgery, University Hospital Tuebingen, Hoppe-Seyler-Strasse 3, 72076 Tuebingen, Germany.
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Abstract
In selection of the right treatment for a specific patient, the surgeon should consider not only the best approach to remove a tumor but also the impact of treatment on the quality of life (QOL) of the patient. Procedures involving extirpation of skull base tumors may be associated with high morbidity. It is therefore important to study patients with skull base neoplasms, because survival differences between various treatment modalities may be small, yet larger differences are expected regarding morbidity. The overall QOL in the majority of patients after skull base tumor resection can be classified as "good," with significant improvement taking place within 12 months following surgery. Patients with carcinomas, acoustic schwannoma, or Cushing's disease suffer from more significant deterioration in their QOL after any intervention. Data retrieved from disease-specific questionnaires revealed that the financial and emotional domains have the worse impact on patients QOL. Old age, malignancy, comorbidity, radiotherapy, and extensive surgery were found to be also negative prognostic factors for QOL. Pain control regimens, antidepressants, and other psychological modalities, including group support, can improve QOL measures in these patients. It is critical that surgeons understand that they cannot assess their patients' perspectives on QOL correctly without asking them. For adequate assessment, validated disease-specific instruments addressing multiple domains of QOL should be utilized.
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Psaras T, Milian M, Hattermann V, Will BE, Tatagiba M, Honegger J. Predictive factors for neurocognitive function and Quality of Life after surgical treatment for Cushing's disease and acromegaly. J Endocrinol Invest 2011; 34:e168-77. [PMID: 21060251 DOI: 10.3275/7333] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cushing's disease (CD) and acromegaly (AC) are associated with impairment in quality of life (QoL) and neurocognition that can persist after successful treatment. AIM To investigate the influence of current disease status (remission vs no remission) on neurocognitive function and QoL in treated CD and AC patients and to determine predictive factors (e.g. demographic, clinical, neurosurgical, endocrinological) for post-operative neurocognition and QoL. SUBJECTS AND METHODS Twenty-four CD and 37 AC patients underwent neuropsychological testing 1 to 10 yr following surgical therapy. Additionally, QoL was assessed. An overnight 2-mg dexamethasone suppression test in CD and IGF-I and GH levels in AC patients were assessed to determine current disease status. The results were compared with 28 sex-, education- and age-matched healthy controls (HC). RESULTS Impaired QoL was more pronounced than neurocognitive decrease in both pathologies compared to HC. This finding was independent of the current status of disease. In AC, persistent comorbidities were associated with impaired QoL (p<0.05). Older age at operation in AC patients was a significant predictor for adverse effects on psychomotor speed and attentional functions (p<0.05). In CD persistent hypocortisolism, not hypercortisolism, had adverse effects on neurocognition (p<0.01). CONCLUSIONS The current status of disease plays a subordinate role in postoperative outcome concerning QoL and neurocognition in either pathology. A possible explanation might be the considerably improved endocrinopathy after treatment compared to untreated patients, even if no cure is achieved. The lasting impairments might be explained by irreversible changes that have occurred during the active phase of the disease.
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Affiliation(s)
- T Psaras
- Division of Pituitary Surgery, Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany.
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Aggleton JP, Dumont JR, Warburton EC. Unraveling the contributions of the diencephalon to recognition memory: a review. Learn Mem 2011; 18:384-400. [PMID: 21597044 PMCID: PMC3101772 DOI: 10.1101/lm.1884611] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 03/13/2011] [Indexed: 11/24/2022]
Abstract
Both clinical investigations and studies with animals reveal nuclei within the diencephalon that are vital for recognition memory (the judgment of prior occurrence). This review seeks to identify these nuclei and to consider why they might be important for recognition memory. Despite the lack of clinical cases with circumscribed pathology within the diencephalon and apparent species differences, convergent evidence from a variety of sources implicates a subgroup of medial diencephalic nuclei. It is supposed that the key functional interactions of this subgroup of diencephalic nuclei are with the medial temporal lobe, the prefrontal cortex, and with cingulate regions. In addition, some of the clinical evidence most readily supports dual-process models of recognition, which assume two independent cognitive processes (recollective-based and familiarity-based) that combine to direct recognition judgments. From this array of information a "multi-effect multi-nuclei" model is proposed, in which the mammillary bodies and the anterior thalamic nuclei are of preeminent importance for recollective-based recognition. The medial dorsal thalamic nucleus is thought to contribute to familiarity-based recognition, but this nucleus, along with various midline and intralaminar thalamic nuclei, is also assumed to have broader, indirect effects upon both recollective-based and familiarity-based recognition.
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Affiliation(s)
- John P Aggleton
- School of Psychology, Cardiff University, Cardiff, CF10 3AT, Wales, United Kingdom.
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Brummelman P, Elderson MF, Dullaart RPF, van den Bergh ACM, Timmer CA, van den Berg G, Koerts J, Tucha O, Wolffenbuttel BHR, van Beek AP. Cognitive functioning in patients treated for nonfunctioning pituitary macroadenoma and the effects of pituitary radiotherapy. Clin Endocrinol (Oxf) 2011; 74:481-7. [PMID: 21133979 DOI: 10.1111/j.1365-2265.2010.03947.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
CONTEXT AND OBJECTIVE Cognitive deterioration is reported in patients with a nonfunctioning pituitary macroadenoma (NFA) and after pituitary radiotherapy. However, reported results are inconsistent and are potentially confounded by different underlying pituitary disorders. The aim of this study was to examine cognitive functions in patients previously treated for NFA with or without radiotherapy. DESIGN Verbal memory was assessed with the Dutch equivalent to the Rey Auditory Verbal Learning Test (15 Words Test, 15 WT). Executive functioning was examined using the Ruff Figural Fluency Test (RFFT). We compared our patient cohort with large reference populations representative of the Dutch population. PATIENTS Eighty-four patients (62±10 years) who underwent transsphenoidal surgery 8.6±6.3 years earlier participated. Patients who underwent radiotherapy (n=39) were compared to those who received surgery alone (n=45). All patients were on stable hormonal replacement therapy. RESULTS The total patient group scored significantly below the reference sample on all 15 WT z-scores (95%CI): short-term memory, -0.3 (-0.5 to -0.1); total memory, -0.8 (-1.1 to -0.5); learning score, -0.3 (-0.5 to -0.1); delayed memory, -0.8 (-1.1 to -0.5), all P<0.01. The total patient group scored significantly below the reference sample on RFFT z-scores (95%CI): unique designs, -0.7 (-0.9 to -0.5) and perseverative errors, -0.5 (-0.8 to -0.2), both P<0.001. Patients who underwent radiotherapy showed no significant differences on cognition when compared to those who received surgery alone. CONCLUSION Patients with NFA score significantly worse on cognition compared to reference populations. Radiotherapy does not appear to have a major influence on cognition.
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Affiliation(s)
- Pauline Brummelman
- Department of Endocrinology, University Medical Center Groningen, The Netherlands.
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Deteriorated executive functions in patients with successful surgery for pituitary adenomas compared with other chronically ill patients. J Int Neuropsychol Soc 2011; 17:369-75. [PMID: 21205414 DOI: 10.1017/s1355617710001645] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Pituitary adenomas, even after successful treatment, are associated with cognitive impairments. It is unclear whether these deficits are a consequence of unspecific factors associated with having a chronic illness and whether the cognitive dysfunctions exceed those of other chronically ill patients. Thirty-eight patients with transsphenoidal surgery for pituitary adenomas and 38 patients undergoing L-thyroxine replacement therapy after thyroid surgery were studied neuropsychologically with established tests. Executive function was examined with the Trail-Making Test A and B, working memory with the digit span test, attention with the digit symbol test, verbal memory with the German version of the Auditory Verbal Learning and Memory Test, and general verbal intelligence by a vocabulary test. Attention (p = .007), attentional speed (p = .0004), executive control (p = .04), and working memory (p = .01), were significantly reduced in patients with pituitary adenomas compared with other chronically ill patients. In contrast, no differences were found between the groups for verbal memory (all subtests: p ≥ .06). Patients with successful surgery for pituitary adenomas show also in comparison with other chronically ill patients an increased risk for deficits in certain aspects of cognitive function, including attention and working memory, supporting the relevance of the brain lesion and its treatment for these dysfunctions.
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Gondi V, Tomé WA, Mehta MP. Why avoid the hippocampus? A comprehensive review. Radiother Oncol 2010; 97:370-6. [PMID: 20970214 PMCID: PMC2997490 DOI: 10.1016/j.radonc.2010.09.013] [Citation(s) in RCA: 263] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 09/04/2010] [Accepted: 09/14/2010] [Indexed: 11/22/2022]
Abstract
In this review article, we provide a detailed and comprehensive discussion of the rationale for using modern IMRT techniques to spare the subgranular zone of the hippocampus during cranial irradiation. We review the literature on neurocognitive effects of cranial irradiation; discuss clinical and preclinical data associating damage to neural progrenitor cells located in subgranular zone of the hippocampus with radiation-induced neurocognitive decline, specifically in terms of short-term memory formation and recall; and present a review of our pilot investigations into the feasibility and risks of sparing the subgranular zone of the hippocampus during whole-brain radiotherapy for brain metastases. We also introduce our phase II cooperative group clinical trial (RTOG 0933) designed to prospectively evaluate the postulated neurocognitive benefit of hippocampal subgranular zone sparing and scheduled to open in 2010.
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Affiliation(s)
- Vinai Gondi
- Department of Human Oncology, University of Wisconsin Comprehensive Cancer Center, Madison, WI 53792, USA.
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Tiemensma J, Kokshoorn NE, Biermasz NR, Keijser BJSA, Wassenaar MJE, Middelkoop HAM, Pereira AM, Romijn JA. Subtle cognitive impairments in patients with long-term cure of Cushing's disease. J Clin Endocrinol Metab 2010; 95:2699-714. [PMID: 20371667 DOI: 10.1210/jc.2009-2032] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT AND OBJECTIVE Active Cushing's disease is associated with cognitive impairments. We hypothesized that previous hypercortisolism in patients with Cushing's disease results in irreversible impairments in cognitive functioning. Therefore, our aim was to assess cognitive functioning after long-term cure of Cushing's disease. DESIGN Cognitive assessment consisted of 11 tests, which evaluated global cognitive functioning, memory, and executive functioning. PATIENTS AND CONTROL SUBJECTS We included 74 patients cured of Cushing's disease and 74 controls matched for age, gender, and education. Furthermore, we included 54 patients previously treated for nonfunctioning pituitary macroadenomas (NFMA) and 54 controls matched for age, gender, and education. RESULTS Compared with NFMA patients, patients cured from Cushing's disease had lower scores on the Mini Mental State Examination (P = 0.001), and on the memory quotient of the Wechsler Memory Scale (P = 0.050). Furthermore, patients cured from Cushing's disease tended to recall fewer words on the imprinting (P = 0.013), immediate recall (P = 0.012), and delayed recall (P = 0.003) trials of the Verbal Learning Test of Rey. On the Rey Complex Figure Test, patients cured from Cushing's disease had lower scores on both trials (P = 0.002 and P = 0.007) compared with NFMA patients. Patients cured from Cushing's disease also made fewer correct substitutions on the Letter-Digit Substitution Test (P = 0.039) and came up with fewer correct patterns on the Figure Fluency Test (P = 0.003) compared with treated NFMA patients. CONCLUSIONS Cognitive function, reflecting memory and executive functions, is impaired in patients despite long-term cure of Cushing's disease. These observations indicate irreversible effects of previous hypercortisolism on cognitive function and, thus, on the central nervous system. These observations may also be of relevance for patients treated with high-dose exogenous glucocorticoids.
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Affiliation(s)
- Jitske Tiemensma
- Department of Endocrinology and Metabolism, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands.
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Younger age is a good predictor of better executive function after surgery for pituitary adenoma in adults. J Int Neuropsychol Soc 2009; 15:803-6. [PMID: 19638252 DOI: 10.1017/s1355617709990324] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pituitary adenomas, even after successful treatment, are associated with cognitive dysfunctions. We hypothesized that an association between the age of the patients at pituitary surgery and neuropsychological outcome may exist. Forty-two patients (mean age 51 +/- 10 years) who had been successfully treated for pituitary adenoma (surgery with or without subsequent radiotherapy) underwent neuropsychological testing. Age at treatment (mean 37 +/- 11 years) was significantly associated with Trail Making Test, Part B (TMT-B) results, a measure of executive control and attention (r = .60, p < .0001). This association remained significant after adjustment for age at testing and time since treatment (r = .42, p = .008). No associations were detected between age at treatment and Trail Making Test, Part A (TMT-A, attentional speed), the digit span test (acoustic working memory), and the German version of the Auditory Verbal Learning and Memory, and Memory Test (verbal memory, all p > or = .3). Our data suggest a favorable effect of younger age at treatment in adults on neurocognitive outcome after surgery for pituitary adenoma.
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39
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Tooze A, Gittoes NJ, Jones CA, Toogood AA. Neurocognitive consequences of surgery and radiotherapy for tumours of the pituitary. Clin Endocrinol (Oxf) 2009; 70:503-11. [PMID: 19178526 DOI: 10.1111/j.1365-2265.2008.03464.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The management of patients with pituitary tumours requires a multidisciplinary approach utilizing a number of different treatment modalities that can impact upon pituitary function and may disrupt important areas of cerebral tissue that are important for normal neurocognitive function. Patients frequently report problems with memory and sustained attention that impact upon normal day-to-day life. At present it is unclear whether any causal link exists between treatments for pituitary tumours and abnormalities of memory and higher mental function. The domains of function affected in patients with pituitary tumours are memory and executive functions, which are involved in the control and direction of lower level, more automatic functions such as attention and motor skills. The evidence for disruption in these modalities is stronger for memory than for executive function. This may be due to variability in study design, insufficient tests and the potential inclusion of fundamentally different tumour types. The purpose of this review is to examine the available evidence to determine whether pituitary disease, its management, or subsequent complications are responsible for any neuropsychological deficits in pituitary patients. Furthermore we address methodological issues that may account for the apparent disparate neurocognitive data that exist in this patient group.
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Affiliation(s)
- Alana Tooze
- Department of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
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40
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Applications of radiotherapy and radiosurgery in the management of pediatric Cushing's disease: a review of the literature and our experience. J Neurooncol 2008; 90:117-24. [PMID: 18568291 DOI: 10.1007/s11060-008-9641-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2008] [Accepted: 06/06/2008] [Indexed: 10/22/2022]
Abstract
Surgical extirpation of pituitary adenomas is considered the mainstay of therapy in pediatric patients with Cushing's disease. However, a small subset of patients will require adjuvant therapy either due to tumor invasiveness, or disease recurrence. Conventional radiation therapy (or radiotherapy) delivers ionizing radiation to control hormonally active cells in fractionated doses (spread out over time) in order to give normal cells time to recover, while radiosurgery involves focusing a high dose of radiation structures in a single treatment session to the adenoma while generally sparing the normal gland and surrounding of any substantial amount of radiation. This paper reviews the effectiveness of radiation in the treatment of pediatric Cushing's disease.
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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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42
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Metellus P, Kharkar S, Kapoor S, Weiss S, Rigamonti D. Cavernous Sinus Meningiomas: Treatment Strategy in the Stereotactic Irradiation Era. ACTA ACUST UNITED AC 2007. [DOI: 10.1097/wnq.0b013e3180600d08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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van Beek AP, van den Bergh ACM, van den Berg LM, van den Berg G, Keers JC, Langendijk JA, Wolffenbuttel BHR. Radiotherapy is Not Associated With Reduced Quality of Life and Cognitive Function in Patients Treated for Nonfunctioning Pituitary Adenoma. Int J Radiat Oncol Biol Phys 2007; 68:986-91. [PMID: 17379436 DOI: 10.1016/j.ijrobp.2007.01.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2006] [Revised: 01/08/2007] [Accepted: 01/08/2007] [Indexed: 10/23/2022]
Abstract
PURPOSE To assess the influence of different treatment modalities on long-term health-related quality of life (HR-QoL) and cognitive problems among patients who had been treated for nonfunctioning pituitary adenoma (NFA). METHODS AND MATERIALS Eighty-one patients (49 men and 32 women, aged 55 +/- 10 years) with a minimal follow-up period of 1 year after treatment for NFA participated in this cross-sectional study. Sixty-two patients were initially treated by transsphenoidal surgery and 19 by craniotomy. Subsequently, 45 of these 81 subjects (56%) received additional radiotherapy (RT) after surgery because of a tumor remnant or regrowth. All subjects filled in standardized questionnaires measuring HR-QoL, depression, fatigue, and cognitive problems. RESULTS Patients who underwent additional RT more frequently underwent a craniotomy and were younger at surgery, but not at entering this study. They also used more hormonal substitution. Most HR-QoL domains showed a similar score in patients who underwent RT when compared with patients who did not receive RT. However, vitality and physical functioning proved to be better in RT subjects, and RT subjects also had better scores for depression and physical and mental fatigue (all p < 0.05). Some aspects of HR-QoL of patients who have been successfully treated for NFA are reduced compared with the normal population, but this was much more pronounced in the group that did not receive RT. In multivariate analysis, RT remained significantly associated with improved HR-QoL. No differences in cognitive function scores were observed. CONCLUSION Postoperative RT in patients with NFA is not associated with reduced quality of life or cognition when compared with surgery alone.
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Affiliation(s)
- André P van Beek
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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44
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Metellus P, Regis J, Muracciole X, Fuentes S, Dufour H, Nanni I, Chinot O, Martin PM, Grisoli F. Evaluation of fractionated radiotherapy and gamma knife radiosurgery in cavernous sinus meningiomas: treatment strategy. Neurosurgery 2006; 57:873-86; discussion 873-86. [PMID: 16284558 DOI: 10.1227/01.neu.0000179924.76551.cd] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To investigate the respective role of fractionated radiotherapy (FR) and gamma knife stereotactic (GKS) radiosurgery in cavernous sinus meningioma (CSM) treatment. METHODS The authors report the long-term follow-up of two populations of patients harboring CSMs treated either by FR (Group I, 38 patients) or GKS radiosurgery (Group II, 36 patients). There were 31 females with a mean age of 53 years in Group I and 29 females with a mean age of 51.2 years in Group II. In 20 patients (Group I) and 13 patients (Group II), FR and GKS radiosurgery were performed as an adjuvant treatment. In 18 patients (Group I) and in 23 patients (Group II), FR and GKS radiosurgery were performed as first line treatment. In our early experience with GKS radiosurgery (1992, date of gamma knife availability in the department), patients with tumors greater than 3 cm, showing close relationship with the optic apparatus (<3 mm) or skull base dural spreading, were treated by FR. Secondarily, with the advent of new devices and our growing experience, these criteria have evolved. RESULTS The median follow-up period was 88.6 months (range, 42-168 mo) for Group I and 63.6 months (range, 48-92 mo) for Group II. According to Sekhar's classification, 26 (68.4%) patients were Grade III to IV in Group I and 10 (27.8%) patients in Group II (P < 0.05); 23 (60.5%) patients had extensive lesions in Group I and 7 (19.4%) patients in Group II (P < 0.05). Mean tumor volume was 13.5 cm in Group I and 5.2 cm in Group II (P < 0.05). Actuarial progression-free survival was 94.7% and 94.4% in Group I and II, respectively. Clinically, improvement was seen for 24 (63.2%) patients in Group I and for 21 (53.8%) patients in Group II (P > 0.05). Radiologically, 11 (29%, Group I) patients and 19 (Group II, 52.7%) patients showed tumor shrinkage (P = 0.04). Transient morbidity was 10.5% in Group I and 2.8% in Group II. Permanent morbidity was 2.6% in Group I and 0% in Group II. CONCLUSION FR and GKS radiosurgery are safe and efficient techniques in treatment of CSMs, affording comparable satisfactory long-term tumor control. However, GKS radiosurgery provides better radiological response, is far more convenient, and fits into most patients lives much better than FR. Therefore, in the authors' opinion, GKS radiosurgery should be advocated in first intention for patients with CSMs, whereas conventional radiotherapy should be reserved for cases that are not amenable to this technique, thus making these two therapeutic modalities not alternative but complementary tools in CS meningioma treatment strategy.
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Affiliation(s)
- Philipe Metellus
- Department of Neurosurgery, Timone Hospital, University of Aix-Marseille II, Marseille, France.
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Schillerstrom JE, Horton MS, Royall DR. The impact of medical illness on executive function. PSYCHOSOMATICS 2006; 46:508-16. [PMID: 16288129 DOI: 10.1176/appi.psy.46.6.508] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Executive function can be defined as one's ability to plan, initiate, sequence, monitor, and inhibit complex goal-directed behaviors. Although executive impairment is generally associated with dementia, recent studies have suggested that patients with chronic diseases, such as hypertension, chronic obstructive pulmonary disease, and diabetes, may also have executive deficits independent of psychiatric comorbidities. Because executive function is associated with functional outcomes, medication compliance, and the capacity to give informed consent, it is important that it be assessed. However, it is the authors' impression that executive function is not adequately assessed in medical settings, despite the availability of reliable measures. This article reviews the impact of medical illness on executive function and discusses practical diagnostic instruments and treatment strategies. The changes in functional status associated with executive impairment as well as pathophysiology and treatment strategies are also discussed.
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Affiliation(s)
- Jason E Schillerstrom
- Department of Psychiatry, University of Texas Health Science Center at San Antonio, TX 78229, and the Geriatric Research Education and Clinical Center, Audie L. Murphy Division, South Texas Veterans Health Administration, USA.
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46
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Affiliation(s)
- M Brada
- Academic Unit of Radiotherapy and Oncology, The Institute of Cancer Research, London, UK.
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47
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Heald AH, Ghosh S, Bray S, Gibson C, Anderson SG, Buckler H, Fowler HL. Long-term negative impact on quality of life in patients with successfully treated Cushing's disease. Clin Endocrinol (Oxf) 2004; 61:458-65. [PMID: 15473878 DOI: 10.1111/j.1365-2265.2004.02118.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A cohort of pituitary tumour patients, who had undergone definitive treatment within a 15-year period at a single neuroscience centre, were investigated as to whether there were differences in psychological well-being and psychosocial functioning, dependent on endocrine pathology and treatment variables. DESIGN A detailed assessment of 114 patients with benign pituitary tumours in relation to primary diagnosis and mode of treatment was carried out. Psychological rating scales used were: the Hospital Anxiety and Depression Scale--UK version (HADS-UK), the World Health Organization Quality of Life Scale--abbreviated version (WHOQOL-BREF), General Health Questionnaire 28 (GHQ-28), the Functional Assessment of Cancer Therapy (FACT) and the Social Adjustment Scale--modified (SAS1 and SAS2; the former completed by the patient and the latter by another person who knows the patient well). All Cushing's patients were biochemically cured as defined by a normal 24-h urine free cortisol excretion within the previous 6 months. RESULTS Patients with treated Cushing's disease had significantly impaired psychological well-being and psychosocial functioning across all tested domains compared with all other pituitary tumours, where scores were similar. When participants with Cushing's disease were excluded, patients who had undergone transfrontal surgery scored significantly higher on GHQ and HADS ratings than transsphenoidally treated patients. CONCLUSION Cushing's disease even when biochemically stable has long-term adverse effects on mood and social functioning. We hypothesize that this may be related to irreversible changes in central neural function. Further studies are necessary to define the precise pathways involved.
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Affiliation(s)
- Adrian H Heald
- Department of Endocrinology, University of Manchester, Salford NHS Trust, Manchester, UK.
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Noad R, Narayanan KR, Howlett T, Lincoln NB, Page RCL. Evaluation of the Effect of Radiotherapy for Pituitary Tumours on Cognitive Function and Quality of Life. Clin Oncol (R Coll Radiol) 2004; 16:233-7. [PMID: 15214645 DOI: 10.1016/j.clon.2004.01.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS Pituitary tumours are often treated with radiotherapy, which can cause cognitive impairment when given in high doses. It is assumed that current regimens do not cause damage, but this has not been established. The aim was to determine whether radiotherapy given to people with pituitary tumours was associated with cognitive impairment and reduced quality of life. MATERIAL AND METHODS We retrospectively compared two outcome groups (patients with pituitary tumours who had undergone radiotherapy and surgery and patients with pituitary tumours who had surgery alone), and carried out standardised tests of cognitive function and quality of life. RESULTS The data suggested that patients with pituitary tumours treated with surgery, with or without radiotherapy, had cognitive impairment compared with the normal population. Patients receiving radiotherapy performed significantly worse than those receiving only surgery on the Stroop test, a measure of executive function. They also scored significantly lower on the Physical Health composite of the SF36, although this difference was no longer significant when account was taken of baseline differences between the groups. There were no significant differences in other cognitive functions, mood, general well-being or the Mental Health Composite of the SF36. CONCLUSIONS Patients treated for pituitary disease may have cognitive impairment. A decrease in cognitive function was found regardless of treatment type. The decrease seemed to be greater in the radiotherapy group and was mainly on executive function. This impairment of executive function could affect daily life. Further prospective studies are required to assess the effect of pituitary disease on cognitive function and the safety of radiotherapy.
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Affiliation(s)
- R Noad
- School of Psychology, University of Nottingham, Nottingham, UK
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Sinai J, Wong AHC. Craniopharyngeoma presenting as psychosis, disinhibition and personality change without neurological signs. Acta Neuropsychiatr 2003; 15:94-6. [PMID: 26984798 DOI: 10.1034/j.1601-5215.2003.00013.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Tumors of the pituitary are associated most commonly with visual changes or endocrine abnormalities. Although a significant proportion of such tumors cause cognitive abnormalities, only a small number of cases have been reported in which the presenting symptoms are primarily 'psychiatric' in nature. The case described below highlights the importance of ancillary investigations in the evaluation of patients admitted to psychiatric wards. Despite the size and extension of the tumor, the patient showed no clear neurological signs, and screening serology was normal except for an elevated prolactin level. Only diagnostic imaging was able to reveal the presence of a calcified, cystic suprasellar mass that was confirmed to be a craniopharyngeoma by histopathology.
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Affiliation(s)
- J Sinai
- 1Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - A H C Wong
- 1Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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50
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Baird A, Sullivan T, Zafar S, Rock J. Quality of life in patients with pituitary tumors: a preliminary study. Qual Manag Health Care 2003; 12:97-105. [PMID: 12747133 DOI: 10.1097/00019514-200304000-00005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patients with pituitary tumors frequently complain of quality of life problems despite normal hormonal blood levels. The goals of the study were to determine whether the sickness-related quality of life reported by these patients was poorer than that expected by the general population and whether some of these complaints and areas of dysfunction were more troublesome than others. Forty-three patients from a southeast Michigan pituitary disorders support group volunteered to complete a survey focusing on demographic, disease data and common complaints plus the Sickness Impact Profile (SIP). The results indicated that mental and physical fatigue were the most troublesome symptoms with sleep and libidinal complaints also of significant concern. The SIP indicated significant discontent among patients with regard to overall quality of life. Although this observational investigation seemed to underscore the fact that patients with pituitary tumors have a decreased quality of life despite apparently normal hormonal status, further subgroup analysis and subsequent surveys will be required to determine the actual significance of these findings.
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Affiliation(s)
- Anne Baird
- Department of Psychiatry, Henry Ford Hospital, Detroit, Michigan, USA
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