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Sumodhee S, Atallah V, Kinj R, Doyen J, L'Homel B, Gillon P, Paquis P, Almairac F, Hieronimus S, Schiappa R, Sadoul JL, Sumodhee D, Pontikos N, Richier Q, Hannoun-Levi JM, Scouarnec C, Chevalier N, Bondiau PY. Fractionated Stereotactic Radiation Therapy for Pituitary Adenomas: An alternative escalating protocol of hypofractionated stereotactic radiotherapy delivering 35Gy in 5 fractions. Cancer Radiother 2021; 26:557-562. [PMID: 34711487 DOI: 10.1016/j.canrad.2021.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 08/03/2021] [Accepted: 08/07/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Evaluate efficacy and toxicity of hypofractionated stereotactic radiotherapy (HSRT) for patients treated for pituitary adenoma (PA) with an alternative HSRT escalating protocol delivering 35Gy in 5 fractions. MATERIAL AND METHODS From June 2007 to March 2017, 29 patients with pituitary adenoma were treated in Antoine Lacassagne Cancer Centre with an alternative HSRT protocol. Prescribed dose was 35Gy in 5 fractions of 7Gy. Radiographic responses were assessed by annual MRI. Hormone blood samples were evaluated each year after HSRT. RESULTS A total of 29 patients aged between 23 and 86 years (median 54 years) were included. Twelve patients received HSRT for recurrent cases and 12 received postoperative adjuvant HSRT, 5 patients did not have surgery. After a median follow-up period of 47 months local control rate was 96%. One patient presented an out-field tumor regrowth 73 months after HSRT. The majority of PA were endocrine-active (18 patients, 62%). After HSRT, 8 patients (44%) presented complete response on initial secretion, 4 patients (23%) presented partial response on initial secretion. Four patients (14%) presented grade 2 or more acute radiation toxicities. One grade 4 visual disorder was observed for one patient. CONCLUSIONS HSRT delivering 35Gy in 5 fractions represents a feasible treatment and shows promising results to reduce hormonal overproduction and to improve local control in PA.
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Affiliation(s)
- S Sumodhee
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France.
| | - V Atallah
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - R Kinj
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - J Doyen
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - B L'Homel
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - P Gillon
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - P Paquis
- Department of Neurosurgery, Centre Hospitalier Universitaire de Nice, Nice, France
| | - F Almairac
- Department of Neurosurgery, Centre Hospitalier Universitaire de Nice, Nice, France
| | - S Hieronimus
- Department of Endocrinology, Centre Hospitalier Universitaire de Nice, Nice, France
| | - R Schiappa
- Department of Biostatistics, Centre Antoine-Lacassagne, Nice, France
| | - J-L Sadoul
- Department of Endocrinology, Centre Hospitalier Universitaire de Nice, Nice, France
| | - D Sumodhee
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College, London, UK
| | - N Pontikos
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Q Richier
- Department of Internal Medicine, CHU de La Réunion, 97400 Saint Denis, France
| | - J-M Hannoun-Levi
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - C Scouarnec
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
| | - N Chevalier
- Department of Neurosurgery, Centre Hospitalier Universitaire de Nice, Nice, France
| | - P-Y Bondiau
- Department of Radiation Oncology, Centre Antoine-Lacassagne, University Côte d'Azur, 33, avenue de Valombrose, 06189 Nice, France
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Uygur MM, Deyneli O, Yavuz DG. Long-term endocrinological outcomes of gamma knife radiosurgery in acromegaly patients. Growth Horm IGF Res 2020; 55:101335. [PMID: 33190108 DOI: 10.1016/j.ghir.2020.101335] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 06/06/2020] [Accepted: 06/06/2020] [Indexed: 12/17/2022]
Abstract
UNLABELLED Gamma knife radiosurgery (GKS) is a treatment option for recurrent or persistent disease in patients with acromegaly. OBJECTIVE We aimed to retrospectively evaluate acromegaly patients who had undergone GKS in terms of pituitary hormone status, efficacy of GKS, and prognostic factors. METHOD One-hundred and ten acromegaly patients who underwent GKS, and who were referred to our outpatient endocrinology clinic between 2007 and 2017, were included in the study. Anterior pituitary hormones and radiology imaging during follow-up were recorded. Remission for acromegaly was defined as a normal insulin-like growth factor 1 (IGF-1) level adjusted for age and gender, and a random growth hormone (GH) level < 1 ng/ml. Endocrine control was defined as normal GH and IGF-1 levels under medication. RESULTS After a mean follow-up of 6.5 ± 4.7 years; remission, endocrine control, and uncontrolled status was observed in 16.4%, 60%, and 23.6% of patients; respectively. Adenoma volume was decreased after GKS (P < .0001). Remnant adenoma diameter was higher in the uncontrolled group compared to the remission and endocrine control group. The presence of tumor extension was associated with disease status (P = .03) and higher initial GH and IGF-1 levels. The mean time after GKS to remission was 26.5 months. Six (5.4%) patients had new-onset pituitary deficiency after GKS. In the multivariate analysis, pre-GKS IGF-1 levels and patient's age were associated with disease status. CONCLUSION GKS is an effective adjuvant treatment with minimal side effects to control GH and IGF-1 levels, increase remission rates, endocrine control, and reduce tumor diameter in persistent acromegaly patients after surgery.
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Affiliation(s)
- Meliha Melin Uygur
- Marmara University School of Medicine, Section of Endocrinology and Metabolism, Istanbul, Turkey.
| | - Oğuzhan Deyneli
- Marmara University School of Medicine, Section of Endocrinology and Metabolism, Istanbul, Turkey
| | - Dilek Gogas Yavuz
- Marmara University School of Medicine, Section of Endocrinology and Metabolism, Istanbul, Turkey
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3
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Hayhurst C, Taylor PN, Lansdown AJ, Palaniappan N, Rees DA, Davies JS. Current perspectives on recurrent pituitary adenoma: The role and timing of surgery vs adjuvant treatment. Clin Endocrinol (Oxf) 2020; 92:89-97. [PMID: 31715012 DOI: 10.1111/cen.14127] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/02/2019] [Accepted: 11/10/2019] [Indexed: 12/15/2022]
Abstract
The clinical course of pituitary adenoma can be highly variable. Aggressive pituitary tumours may require multimodal therapy with multiple operations. Even standard pituitary adenomas exhibit relatively high long-term recurrence rates and delayed intervention is often required. The indications for revision surgery in the endoscopic era are expanding for both functioning and nonfunctioning tumours, including access to the cavernous sinus and intracranial compartments. Although revision surgery can be challenging, it has been demonstrated to be both safe and effective. The question of the use of early radiotherapy in pituitary adenoma remains controversial. Our increasing understanding of pituitary tumour biology facilitates individualized treatment and surveillance protocols, with early intervention in high-risk adenoma subtypes. In this review, we discuss the treatment options for recurring pituitary tumours and focus on the role of revision surgery.
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Affiliation(s)
- Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Peter N Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | - Andrew J Lansdown
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
| | | | - Dafydd Aled Rees
- Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK
| | - John Stephen Davies
- Centre for Diabetes and Endocrinology, University Hospital of Wales, Cardiff, UK
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4
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Ischemic stroke after radiation therapy for pituitary adenomas: a systematic review. J Neurooncol 2017; 135:1-11. [PMID: 28660317 PMCID: PMC5658475 DOI: 10.1007/s11060-017-2530-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 06/10/2017] [Indexed: 12/13/2022]
Abstract
Radiation therapy is widely used for the treatment of residual and recurrent pituitary adenomas and proved to effectively control tumor growth. However, it is suggested that this treatment might result in an increased risk of ischemic stroke. This review aims to evaluate the radiotherapy-related risk of stroke in pituitary adenoma patients. PubMed and Embase databases were systematically searched for current literature on ischemic stroke risk after radiotherapy in pituitary adenoma, in accordance with the PRISMA statement. Two authors independently selected eligible studies and extracted data. The New Castle Ottawa-scale was used for quality assessment. Out of 264 publications, 11 studies were selected, including 4394 irradiated patients. Incidence of ischemic stroke ranged from 0 to 11.6% (mean 6.7%). While one large, long term follow-up study showed a threefold increased risk of stroke after radiation therapy, another nationwide study of high quality found no significant difference in stroke risk after irradiation. Four studies, which applied stereotactic radiosurgery (SRS) or Gamma-knife surgery (GKS), found no ischemic strokes. Included studies described different radiation techniques and regimens and different lengths of follow-up. In conclusion, complications of cerebral ischemia after radiotherapy for pituitary adenoma are infrequently reported. Moreover, after correction for several confounders, no significant difference in ischemic stroke rate between irradiated and non-irradiated patients could be identified.
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Safety and efficacy of fractionated stereotactic radiotherapy and stereotactic radiosurgery for treatment of pituitary adenomas: A systematic review and meta-analysis. J Neurol Sci 2016; 372:110-116. [PMID: 28017195 DOI: 10.1016/j.jns.2016.11.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 11/11/2016] [Accepted: 11/13/2016] [Indexed: 01/11/2023]
Abstract
Accumulated studies have not provided conclusive evidence in regards to the comparative efficacy and safety of fractionated stereotactic radiotherapy and stereotactic radiosurgery for treatment of pituitary adenomas. To address this issue, we performed a meta-analysis with eight studies identified from Medline, PubMed, Cochrane, Google Scholar, and published up to September 17, 2015. Eligible studies reported the disease control rate, endocrine cure rate (for functional adenomas), the rate of occurrence of new-onset hypopituitarism, and visual disturbance rate in patients treated with either stereotactic radiosurgery or fractionated stereotactic radiotherapy. Eight studies enrolled a total of 634 patients with pituitary adenoma, 273 patients underwent a stereotactic radiosurgery and 361 patients underwent fractionated stereotactic radiotherapy. No significant differences were found in efficacy measures, such as disease control rate and endocrine cure rate, between stereotactic radiosurgery and fractionated stereotactic radiotherapy (OR=1.156, p=0.666; OR=0.659, p=0.153, respectively). Additionally, meta-analysis of safety measures, such as the rate of new-onset hypopituitarism and visual disturbance rate, did not show significant differences between different treatments (OR=1.365, p=0.469; OR=0.872, p=0.845 respectively). In conclusion, both stereotactic radiosurgery and fractionated stereotactic radiotherapy have comparable efficacy and safety in the management of pituitary adenoma patients.
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Lin AL, Sum MW, DeAngelis LM. Is there a role for early chemotherapy in the management of pituitary adenomas? Neuro Oncol 2016; 18:1350-6. [PMID: 27106409 DOI: 10.1093/neuonc/now059] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 03/16/2016] [Indexed: 12/25/2022] Open
Abstract
Pituitary adenomas are benign intracranial neoplasms that are frequently well-controlled with standard treatments that include surgical resection, radiotherapy, and agents that modulate hormonal excess. Unfortunately, a subset of patients remains uncontrolled or develops complications from these interventions. For these patients, chemotherapy is an additional treatment option that could improve outcomes. Temozolomide is an oral chemotherapy with a favorable side-effect profile that has shown activity against pituitary adenomas. Its non-overlapping toxicity and ability to induce rapid tumor regression renders it a potentially important adjunctive treatment. In patients with tumors that cannot be optimally addressed with standard treatments, there may be a role for early initiation of temozolomide.
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Affiliation(s)
- Andrew L Lin
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.L.L., L.M.D.A.)
| | - Melissa W Sum
- Division of Endocrinology, Columbia University Medical Center, New York, New York (M.W.S.)
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York (A.L.L., L.M.D.A.)
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Abstract
Acromegaly is a rare condition of GH excess associated with significant morbidities (e.g. hypertension, glucose intolerance or diabetes mellitus, cardiac, cerebrovascular, respiratory disease and arthritis) and, when uncontrolled, high mortality. Surgery, medical treatment and radiotherapy remain our therapeutic tools. Advances in these options during the last years have offered further perspectives in the management of patients and particularly those with challenging tumours; the impact of these on the long-term morbidity and mortality remains to be assessed.
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Affiliation(s)
- Georgia Ntali
- Department of Endocrinology and Diabetes, Alexandra Hospital, 80 Vas. Sofias St, Athens, 11528, Greece
| | - Niki Karavitaki
- Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine, University of Birmingham, Wolfson Drive, Edgbaston, Birmingham, B15 2TT, UK
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Diallo AM, Colin P, Litre CF, Diallo MM, Decoudier B, Bertoin F, Higel B, Patey M, Rousseaux P, Delemer B. Long-term results of fractionated stereotactic radiotherapy as third-line treatment in acromegaly. Endocrine 2015; 50:741-8. [PMID: 25956280 DOI: 10.1007/s12020-015-0610-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 04/15/2015] [Indexed: 12/18/2022]
Abstract
The treatment of acromegaly is based on surgery, drugs, and radiotherapy as a third-line option. Fractionated stereotactic radiotherapy (FSRT) is a new technique with a need for long-term evaluation. The purpose of the study was to evaluate long-term results of FSRT in acromegaly. Overall, 34 patients [sex ratio 1.12, age 45 (5-65) years] with a pituitary adenoma of 24.5 (9-76) mm including 20 invasive tumors were treated by radiotherapy in fractionated stereotactic conditions delivering 50 gy in 27 sessions. Baseline growth hormone (GH) and IGF1 levels were 18 (±14.5) and 632.6 (±339) µg/L, respectively. Indications of FSRT were failure of surgery and drug treatments (n = 30) or contraindication/refusal of surgery (n = 4). Hormonal control was defined by normal age- and sex-adjusted IGF1. Remission was defined by hormonal control after withdrawal of drugs for a minimum of three consecutive months. Data were analyzed in SPSS software with a significance level at p < 0.05. After a mean follow-up of 152 months, hormonal control was achieved in 33 patients (97 %) with withdrawal of drugs in 13 patients (38.2 %) without any recurrence. Factors found to be significantly associated to remission in a multivariate Cox regression were lower baseline hormone levels (GH and IGF1) and smaller tumor size. Tumor control was achieved in all patients. Acquired hypopituitarism after radiotherapy was the main side effect reported with a rate of 39 %. FSRT seems to be an effective and well tolerated third-line treatment of acromegaly, particularly adapted to macro adenomas treatment.
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Affiliation(s)
- Alpha M Diallo
- Department of Endocrinology, Diabetes, and Nutrition, University Hospital of Reims, 51092, Reims, France
| | - Philippe Colin
- Center of Radiotherapy, Institute of Cancer Courlancy Reims, 51100, Reims, France
| | - Claude F Litre
- Department of Neurosurgery, University Hospital of Reims, 51092, Reims, France
| | - Mamadou M Diallo
- Depatment of Endocrinology and Metabolism, University Hospital of Donka, Conakry, Guinea
| | - Bénédicte Decoudier
- Department of Endocrinology, Diabetes, and Nutrition, University Hospital of Reims, 51092, Reims, France
| | - Florence Bertoin
- Department of Endocrinology, Diabetes, and Nutrition, University Hospital of Reims, 51092, Reims, France
| | - Brigitte Higel
- Department of Radiology, University Hospital of Reims, 51092, Reims, France
| | - Martine Patey
- Department of Anatomy and Pathology, University Hospital of Reims, 51092, Reims, France
| | - Pascal Rousseaux
- Department of Neurosurgery, University Hospital of Reims, 51092, Reims, France
| | - Brigitte Delemer
- Department of Endocrinology, Diabetes, and Nutrition, University Hospital of Reims, 51092, Reims, France.
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Margusino-Framiñán L, Pertega-Diaz S, Pena-Bello L, Sangiao-Alvarellos S, Outeiriño-Blanco E, Pita-Gutierrez F, Pita-Fernandez S, Cordido F. Cost-effectiveness analysis of preoperative treatment of acromegaly with somatostatin analogue on surgical outcome. Eur J Intern Med 2015; 26:736-41. [PMID: 26300269 DOI: 10.1016/j.ejim.2015.07.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Revised: 04/19/2015] [Accepted: 07/29/2015] [Indexed: 01/28/2023]
Abstract
CONTEXT There is no uniform standard of care for acromegaly. Due to the high costs involved, steps must be taken to ensure the cost-effective delivery of treatment. OBJECTIVE Taking the results of an earlier meta-analysis as a starting point, this study aims to determine whether treatment with long-acting somatostatin analogue (SSA) prior to surgery improves the cost-effectiveness of the treatment of acromegaly. METHODS The results are presented as an Incremental Cost Effectiveness Ratio (ICER) immediately after surgery, for the following year and over the next four decades. The cure rates percentage (95% CI) for the three randomized prospective controlled trials were 44.4% (34.2-54.7) and 18.2% (10.1-26.3) for preoperative treated and untreated patients respectively. The cost of pharmacological treatments was based on the number of units prescribed, dose and length of treatment. RESULTS The mean (95% CI) ICER immediately after surgery was €17,548 (12,007-33,250). In terms of the postoperative SSA treatment, the ICER changes from positive to negative before two years after surgery. One decade after surgery the ICER per patient/year was €-9973 (-18,798; -6752) for postoperative SSA treatment and €-31,733 (-59,812; -21,483) in the case of postoperative pegvisomant treatment. CONCLUSIONS In centres without optimal surgical results, preoperative treatment of GH-secreting pituitary macroadenomas with SSA not only shows a significant improvement in the surgical results, but is also highly cost-effective, with an ICER per patient/year one decade after surgery, of between €-9973 (-18,798; -6752) and €-31,733 (-59,812; -21,483) for SSA and pegvisomant respectively.
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Affiliation(s)
| | - Sonia Pertega-Diaz
- Clinical Epidemiology and Biostatistics Unit, University Hospital A Coruña, A Coruña, Spain
| | - Lara Pena-Bello
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, A Coruña, Spain
| | - Susana Sangiao-Alvarellos
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, A Coruña, Spain; Department of Medicine, Faculty of Health Sciences, University of A Coruña, A Coruña, Spain
| | | | | | | | - Fernando Cordido
- Instituto de Investigación Biomedica (INIBIC), University Hospital A Coruña, A Coruña, Spain; Department of Medicine, Faculty of Health Sciences, University of A Coruña, A Coruña, Spain; Department of Endocrinology, University Hospital A Coruña, A Coruña, Spain.
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Abstract
INTRODUCTION Pituicytoma is a rare tumor arising from the neurohypophysis or pars intermedia of the adenohypophysis. CASE REPORT A 36 year old male came to our observation presenting polydipsia, polyuria, polyphagia, decreased libido and altered sleep-wake rhythm. The biochemical tests showed hypotonic urine, mild hyperprolactinemia, hypogonadotropic hypogonadism, central hypothyroidism. Magnetic resonance revealed an expansive lesion of the suprasellar region (slightly isointense on T1, hyperintense on T2, impregnating contrast medium), that was partially removed by trans-cranial neurosurgical approach. The histopathological diagnosis was pituicytoma. After surgery, in addition to endocrine disorders, the patient presented severe neurological sequelae and hyperthermia, likely due to damage of the hypothalamus, followed by a progressive metabolic syndrome. The residual tumor was monitored by MRI, and, due to the early gradual increase in volume, was treated by stereotactic radiosurgery. DISCUSSION/CONCLUSIONS Pituicytomas are often difficult to distinguish from other hypothalamic or pituitary lesions. However, their identification would be preferable in a pre-operative setting in order to optimize the work-up and to initiate a proactive management of the expected complications.
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Affiliation(s)
- Claudia Teti
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, Center of Excellence for Biomedical Research, University of Genoa, Viale Benedetto XV 6, 16132, Genoa, Italy
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11
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Boström JP, Kinfe T, Meyer A, Pintea B, Gerlach R, Surber G, Lammering G, Hamm K. Treatment of acromegaly patients with risk-adapted single or fractionated stereotactic high-precision radiotherapy: High local control and low toxicity in a pooled series. Strahlenther Onkol 2015; 191:477-85. [PMID: 25575977 DOI: 10.1007/s00066-014-0802-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Accepted: 12/18/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this work was to evaluate a prospectively initiated two-center protocol of risk-adapted stereotactic radiosurgery (SRS) or stereotactic radiotherapy (SRT) in patients with acromegaly. PATIENTS AND METHODS In total 35 patients (16 men/19 women, mean age 54 years) were prospectively included in a treatment protocol of SRS [planning target volume (PTV < 4 ccm, > 2 mm to optic pathways = low risk] or SRT (PTV ≥ 4 ccm, ≤ 2 mm to optic pathways = high risk). The mean tumor volume was 3.71 ccm (range: 0.11-22.10 ccm). Based on the protocol guidelines, 21 patients were treated with SRS and 12 patients with SRT, 2 patients received both consecutively. RESULTS The median follow-up (FU) reached 8 years with a 5-year overall survival (OS) of 87.3% [confidence interval (CI): 70.8-95.6%] and 5-year local control rate of 97.1% (CI: 83.4-99.8%). Almost 80% (28/35) presented tumor shrinkage during FU. Endocrinological cure was achieved in 23% and IGF-1 normalization with reduced medication was achieved in 40% of all patients. An endocrinological response was generally achieved within the first 3 years, but endocrinological cure can require more than 8 years. A new adrenocorticotropic hypopituitarism occurred in 13 patients (46.4%). A new visual field disorder and a new oculomotor palsy occurred in 1 patient, respectively. Patients with occurrence of visual/neurological impairments had a longer FU (p = 0.049). CONCLUSION Our SRS/SRT protocol proved to be safe and successful in terms of tumor control and protection of the visual system. The timing and rate of endocrine improvements are difficult to predict. One has to accept an unavoidable rate of additional adrenocorticotropic hypopituitarism in the long term.
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Affiliation(s)
- Jan Patrick Boström
- Department of Radiosurgery and Stereotactic Radiotherapy, Mediclin Robert Janker Clinic and MediClin MVZ Bonn, Villenstrasse 8, 53129, Bonn, Germany,
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12
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Pekic S, Popovic V. Alternative causes of hypopituitarism: traumatic brain injury, cranial irradiation, and infections. HANDBOOK OF CLINICAL NEUROLOGY 2014; 124:271-90. [PMID: 25248593 DOI: 10.1016/b978-0-444-59602-4.00018-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Hypopituitarism often remains unrecognized due to subtle clinical manifestations. Anterior pituitary hormone deficiencies may present as isolated or multiple and may be transient or permanent. Traumatic brain injury (TBI) is recognized as a risk factor for hypopituitarism, most frequently presenting with isolated growth hormone deficiency (GHD). Data analysis shows that about 15% of patients with TBI have some degree of hypopituitarism which if not recognized may be mistakenly ascribed to persistent neurologic injury and cognitive impairment. Identification of predictors for hypopituitarism after TBI is important, one of them being the severity of TBI. The mechanisms involve lesions in the hypothalamic-pituitary axis and inflammatory changes in the central nervous system (CNS). With time, hypopituitarism after TBI may progress or reverse. Cranial irradiation is another important risk factor for hypopituitarism. Deficiencies in anterior pituitary hormone secretion (partial or complete) occur following radiation damage to the hypothalamic-pituitary region, the severity and frequency of which correlate with the total radiation dose delivered to the region and the length of follow-up. These radiation-induced hormone deficiencies are irreversible and progressive. Despite numerous case reports, the incidence of hypothalamic-pituitary dysfunction following infectious diseases of the CNS has been underestimated. Hypopituitarism usually relates to the severity of the disease, type of causative agent (bacterial, TBC, fungal, or viral) and primary localization of the infection. Unrecognized hypopituitarism may be misdiagnosed as postencephalitic syndrome, while the presence of a sellar mass with suprasellar extension may be misdiagnosed as pituitary macroadenoma in a patient with pituitary abscess which is potentially a life-threatening disease.
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Affiliation(s)
- Sandra Pekic
- Faculty of Medicine, University of Belgrade, and Clinic of Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center Belgrade, Belgrade, Serbia
| | - Vera Popovic
- Faculty of Medicine, University of Belgrade, and Clinic of Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center Belgrade, Belgrade, Serbia.
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Abstract
INTRODUCTION Evidence-based treatment guidelines have undoubtedly advanced medical practice and supported optimal management of acromegaly, but their application may be hampered by limited access to the latest treatment options. METHODS In this retrospective, narrative review, the authors revisited existing treatment guidelines for acromegaly in Latin America. These were considered in conjunction with published evidence chosen at the authors' discretion. FINDINGS In a socially and economically diverse region, such as Latin America, any regional practice guidelines need to appreciate that recommended treatment options, such as surgery by expert pituitary surgical teams and drug therapies, especially somatostatin analogs, are often not available due to limited resources. In these instances, physicians may be obliged to apply less effective therapeutic options. CONCLUSIONS The current article looks at the practical aspects of acromegaly management in Latin America and discusses this in the context of existing guidelines. Furthermore, we consider potential strategies to make better use of resources through combination and multimodal approaches to treatment.
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Affiliation(s)
- Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, Av. Dr. Eneas de Carvalho, 255, 7ºandar, sala 7037, São Paulo, CEP 05403-000, Brazil,
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Acromegaly: a single centre's experience of stereotactic radiosurgery and radiotherapy for growth hormone secreting pituitary tumours with the linear accelerator. J Clin Neurosci 2013; 20:1506-13. [PMID: 23911106 DOI: 10.1016/j.jocn.2012.11.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 11/07/2012] [Accepted: 11/17/2012] [Indexed: 01/05/2023]
Abstract
Primary treatment for growth-hormone secreting pituitary adenomas usually involves surgery, with treatment options for recurrent and persistent disease including repeat surgery, medication and radiation therapy. The majority of previously published series for radiation therapy in acromegaly in the past 20 years have been based on Gamma-Knife (Elekta, Stockholm, Sweden) surgery. To our knowledge, we present the largest series of linear accelerator-based treatment for this disease, with a review of 121 patients treated at our institution; since 1990, 86 patients underwent stereotactic radiosurgery (SRS), 10 patients underwent fractionated stereotactic radiotherapy (FSRT), and for the purposes of comparison we also reviewed 25 patients who underwent conventional radiotherapy prior to 1990. Tumour volume control in all three groups was excellent and consistent with previously reported literature - only three of 86 (4%) patients undergoing SRS had a documented increase in tumour size, and none of the patients undergoing FSRT had a documented increase in size following a median follow-up of 5.5 and 5.1 years for SRS and FSRT, respectively. Target growth hormone levels of <2.5 ng/mL were met by 12 of 86 (14%) of the SRS group, and by two of 10 (20%) in the FSRT group. Target insulin-like growth factor-1 levels of age and sex matched controls were achieved in 16 of 86 patients (18.6%) post-SRS and five of 10 patients (50%) post-FSRT. New hormonal deficits requiring replacement therapy were identified in 17 of 86 (19.8%) patients post-SRS which is consistent with previously published radiosurgical series. Identified non-hormonal morbidity was low (<5%).
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Vallette S, Ezzat S, Chik C, Ur E, Imran SA, Van Uum S, Rivera J, Caspar-Bell G, Serri O. Emerging trends in the diagnosis and treatment of acromegaly in Canada. Clin Endocrinol (Oxf) 2013. [PMID: 23190441 DOI: 10.1111/cen.12112] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate demographic data and quality of care of patients with acromegaly in Canada and their evolution over time and secondly, to evaluate predictors of co-morbidities and treatment outcomes. DESIGN AND PATIENTS Retrospective analyses of clinical, biochemical and treatment outcome data of 649 patients with acromegaly (males: 50·7%) followed from 1980 to 2010 (mean 10·2 years, SD 13·7) in eight tertiary care centres from six Canadian provinces. RESULTS In comparison to 1980-1994, the number of patients referred with acromegaly in the last 15 years was higher with female preponderance (52·8% vs 41·4%, P = 0·01) and an older age at diagnosis (46·4 ± 14 vs 41·3 ± 12 years, P < 0·0001). Diabetes was present in 28%, hypertension in 37% and sleep apnoea in 33% of cases. Pretreatment IGF-1 levels, but not GH levels were significant predictors of diabetes (P = 0·0002) and hypertension (P < 0·0001). Eighty-nine per cent of patients underwent pituitary surgery, 64·5% had medical therapy and 22% received radiotherapy. Radiotherapy was less utilized in the past 15 years (16% vs 45%, P < 0·0001). Multimodal therapy achieved remission or control of acromegaly in 70% of patients. Patients in remission or disease control had lower initial random GH (P = 0·04) and IGF-1 levels (P < 0·0001). Hypopituitarism was present in 23% of patients and cancer in 8·5%. CONCLUSIONS There was an increase over time of referral for acromegaly management with female predilection. Initial higher IGF-1, but not GH levels, were predictive of co-morbidities and persistent active disease after treatment. Disease remission or control was attained in 70% of patients utilizing multimodal therapy.
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Jallad RS, Bronstein MD. The place of medical treatment of acromegaly: current status and perspectives. Expert Opin Pharmacother 2013; 14:1001-15. [PMID: 23600991 DOI: 10.1517/14656566.2013.784744] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Acromegaly is characterized by elevated growth hormone (GH) and insulin-like growth factor-I (IGF-I) levels and by progressive somatic disfigurement and systemic manifestations, which lead to a mortality rate higher than the general population. Therefore, diagnosis and properly treatment should be performed as soon as possible. AREAS COVERED This article focuses on the state of the art of acromegaly medical treatment. Somatostatin analogs, dopamine agonists and GH receptor antagonist were reviewed. Somatostatin analogs, the first-choice pharmacotherapy, can be used as primary or pre-operative treatment or as secondary therapy after failed surgery. Dopamine agonists have been used in patients with slightly elevated hormone levels and/or mixed GH/prolactin adenomas. Pegvisomant is indicated for resistant to somatostatin analogs/dopamine agonists. Combined treatment is also an option for resistant cases. Other non-conventional therapies and perspectives of treatment were also been discussed. EXPERT OPINION The control of disease activity in acromegaly is of paramount importance. Medical treatment is an important option for cases in which surgery was unsuccessful or not indicated. Despite the achievements in medical treatment, somatotropic tumor aggressiveness and/or resistance to the drugs currently available remain a concern. Therefore, novel therapy targets based on molecular pathogenesis of GH-secreting tumors are currently in development, aiming at fulfilling this important gap.
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Affiliation(s)
- Raquel S Jallad
- University of Sao Paulo Medical School, Hospital das Clinicas, Division of Endocrinology and Metabolism, Neuroendocrine Unit, São Paulo, Brasil
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