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Eekers DBP, Zegers CML, Ahmed KA, Amelio D, Gupta T, Harrabi SB, Kazda T, Scartoni D, Seidel C, Shih HA, Minniti G. Controversies in neuro-oncology: Focal proton versus photon radiation therapy for adult brain tumors. Neurooncol Pract 2024; 11:369-382. [PMID: 39006517 PMCID: PMC11241386 DOI: 10.1093/nop/npae040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Abstract
Radiation therapy (RT) plays a fundamental role in the treatment of malignant and benign brain tumors. Current state-of-the-art photon- and proton-based RT combines more conformal dose distribution of target volumes and accurate dose delivery while limiting the adverse radiation effects. PubMed was systematically searched from from 2000 to October 2023 to identify studies reporting outcomes related to treatment of central nervous system (CNS)/skull base tumors with PT in adults. Several studies have demonstrated that proton therapy (PT) provides a reduced dose to healthy brain parenchyma compared with photon-based (xRT) radiation techniques. However, whether dosimetric advantages translate into superior clinical outcomes for different adult brain tumors remains an open question. This review aims at critically reviewing the recent studies on PT in adult patients with brain tumors, including glioma, meningiomas, and chordomas, to explore its potential benefits compared with xRT.
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Affiliation(s)
- Danielle B P Eekers
- Department of Radiation Oncology (Maastro), Maastricht University Medical Center, GROW-School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Catharina M L Zegers
- Department of Radiation Oncology (Maastro), Maastricht University Medical Center, GROW-School for Oncology and Reproduction, Maastricht, The Netherlands
| | - Kamran A Ahmed
- Departments of Oncologic Sciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
- Department of Radiation Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Dante Amelio
- Trento Proton Therapy Center, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Tejpal Gupta
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Semi Ben Harrabi
- Department of Radiation Oncology, Heidelberg Ion Beam Therapy Center (HIT), University Hospital Heidelberg, Heidelberg, Germany
| | - Tomas Kazda
- Department of Radiation Oncology, Faculty of Medicine, Masaryk University and Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Daniele Scartoni
- Trento Proton Therapy Center, Azienda Provinciale per i Servizi Sanitari (APSS), Trento, Italy
| | - Clemens Seidel
- Comprehensive Cancer Center Central Germany, Leipzig, Germany
- Department of Radiation Oncology, University of Leipzig Medical Center, Leipzig, Germany
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Giuseppe Minniti
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
- IRCCS Neuromed, Pozzilli IS, Italy
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Ishimoto Y, Ide S, Watanabe K, Oyu K, Kasai S, Umemura Y, Sasaki M, Nagaya H, Tatsuo S, Nozaki A, Ikushima Y, Wakayama T, Asano K, Saito A, Tomiyama M, Kakeda S. Usefulness of pituitary high-resolution 3D MRI with deep-learning-based reconstruction for perioperative evaluation of pituitary adenomas. Neuroradiology 2024; 66:937-945. [PMID: 38374411 DOI: 10.1007/s00234-024-03315-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 02/12/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE To evaluate the diagnostic value of T1-weighted 3D fast spin-echo sequence (CUBE) with deep learning-based reconstruction (DLR) for depiction of pituitary adenoma and parasellar regions on contrast-enhanced MRI. METHODS We evaluated 24 patients with pituitary adenoma or residual tumor using CUBE with and without DLR, 1-mm slice thickness 2D T1WI (1-mm 2D T1WI) with DLR, and 3D spoiled gradient echo sequence (SPGR) as contrast-enhanced MRI. Depiction scores of pituitary adenoma and parasellar regions were assigned by two neuroradiologists, and contrast-to-noise ratio (CNR) was calculated. RESULTS CUBE with DLR showed significantly higher scores for depicting pituitary adenoma or residual tumor compared to CUBE without DLR, 1-mm 2D T1WI with DLR, and SPGR (p < 0.01). The depiction score for delineation of the boundary between adenoma and the cavernous sinus was higher for CUBE with DLR than for 1-mm 2D T1WI with DLR (p = 0.01), but the difference was not significant when compared to SPGR (p = 0.20). CUBE with DLR had better interobserver agreement for evaluating adenomas than 1-mm 2D T1WI with DLR (Kappa values, 0.75 vs. 0.41). The CNR of the adenoma to the brain parenchyma increased to a ratio of 3.6 (obtained by dividing 13.7, CNR of CUBE with DLR, by 3.8, that without DLR, p < 0.01). CUBE with DLR had a significantly higher CNR than SPGR, but not 1-mm 2D T1WI with DLR. CONCLUSION On the contrast-enhanced MRI, compared to CUBE without DLR, 1-mm 2D T1WI with DLR and SPGR, CUBE with DLR improves the depiction of pituitary adenoma and parasellar regions.
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Affiliation(s)
- Yuka Ishimoto
- Department of Radiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Satoru Ide
- Department of Radiology, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan.
| | - Keita Watanabe
- Open Innovation Institute, Kyoto University, Kyoto, Japan
| | - Kazuhiko Oyu
- Department of Radiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Sera Kasai
- Department of Radiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yoshihito Umemura
- Department of Radiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Miho Sasaki
- Department of Radiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Haruka Nagaya
- Department of Radiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Soichiro Tatsuo
- Department of Radiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | | | | | | | - Kenichiro Asano
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Atsushi Saito
- Department of Neurosurgery, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Masahiko Tomiyama
- Department of Neurology, Hirosaki University School of Medicine, Hirosaki, Aomori, Japan
| | - Shingo Kakeda
- Department of Radiology, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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Spaniol M, Abo-Madyan Y, Ruder AM, Fleckenstein J, Giordano FA, Stieler F. Homogenous dose prescription in Gamma Knife Radiotherapy: Combining the best of both worlds. Phys Med 2024; 117:103202. [PMID: 38159546 DOI: 10.1016/j.ejmp.2023.103202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/28/2023] [Accepted: 12/21/2023] [Indexed: 01/03/2024] Open
Abstract
PURPOSE Stereotactic radiosurgery with linear accelerators (LINACs) or Leksell Gamma Knife® (LGK, Elekta AB) is an established treatment option for intracranial tumors. When those are involving/abutting organs at risk (OAR), homogenous and normofractionated treatments outmatch single fraction deliveries. In such situations, it would be desirable to balance LINAC's homogeneity benefits with LGK's dose gradient attributes. In this study, we determined homogeneity and OAR sparing ranges using a non-clinical, homogenous prototype version of LGK Lightning. METHODS We retrospectively analyzed thirty fractionated LGK Icon in-house patients with acoustic neuromas, pituitary adenomas and meningiomas. Four treatment plans were generated (54 Gy,1.8 Gy/fx) per patient: one LINAC plan, one clinical Lightning plan ("LGK") and two prototype Lightning plans ("LGK Hom" and "LGK OAR"). We analyzed Dmean and D2% for different OAR, Gradient Index (GI), Paddick Conformity Index (PCI), Homogeneity Index (HI) and beam-on-time (BOT). RESULTS While the LINAC vs. Lightning plans (LGK Hom|LGK OAR|LGK) boast better homogeneity (median: 1.08 vs. 1.18|1.24|1.35) and shorter BOT (median: 137 s vs. 432 s|510 s|510 s), Lightning plans show improved GI (median: 6.68 vs. 3.86|3.50|3.19), similar PCI (median: 0.75 vs. 0.76|0.75|0.82) and significantly reduced OAR doses. For in-tumor OAR, LGK Hom and LINAC plans achieves similar OAR sparing with improved GI for LGK Hom. CONCLUSIONS This study is a preliminary attempt to combine the dosimetric advantages of LINAC and LGK treatment planning. We observed that LGK plan homogeneity can be improved toward LINAC standards while maintaining the LGK advantage of favorable OAR doses and GI. Additionally, in-tumor OAR hotspots can be considerably reduced.
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Affiliation(s)
- Manon Spaniol
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Yasser Abo-Madyan
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Arne M Ruder
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Jens Fleckenstein
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Frank A Giordano
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
| | - Florian Stieler
- Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany.
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Tawfik ZA, Farid MEA, El Shahat KM, Hussein AA, Al Etreby M. Approaches for Stereotactic Radiosurgery (SRS)/Stereotactic Radiotherapy (SRT) in brain metastases using different radiotherapy modalities (Feasibility study). JOURNAL OF X-RAY SCIENCE AND TECHNOLOGY 2024; 32:765-781. [PMID: 38277334 DOI: 10.3233/xst-230275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
BACKGROUND SRS and SRT are precise treatments for brain metastases, delivering high doses while minimizing doses to nearby organs. Modern linear accelerators enable the precise delivery of SRS/SRT using different modalities like three-dimensional conformal radiotherapy (3DCRT), intensity-modulated radiotherapy (IMRT), and Rapid Arc (RA). OBJECTIVE This study aims to compare dosimetric differences and evaluate the effectiveness of 3DCRT, IMRT, and Rapid Arc techniques in SRS/SRT for brain metastases. METHODS 10 patients with brain metastases, 3 patients assigned for SRT, and 7 patients for SRS. For each patient, 3 treatment plans were generated using the Eclipse treatment planning system using different treatment modalities. RESULTS No statistically significant differences were observed among the three techniques in the homogeneity index (HI), maximum D2%, and minimum D98% doses for the target, with a p > 0.05. The RA demonstrated a better conformity index of 1.14±0.25 than both IMRT 1.21±0.26 and 3DCRT 1.37±0.31. 3DCRT and IMRT had lower Gradient Index values compared to RA, suggesting that they achieved a better dose gradient than RA. The mean treatment time decreased by 26.2% and 10.3% for 3DCRT and RA, respectively, compared to IMRT. In organs at risk, 3DCRT had lower maximum doses than IMRT and RA, but some differences were not statistically significant. However, in the brain stem and brain tissues, RA exhibited lower maximum doses compared to IMRT and 3DCRT. Additionally, RA and IMRT had lower V15Gy, V12Gy, and V9Gy values compared to 3DCRT. CONCLUSION While 3D-CRT delivered lower doses to organs at risk, RA and IMRT provided better conformity and target coverage. RA effectively controlled the maximum dose and irradiated volume of normal brain tissue. Overall, these findings indicate that 3DCRT, RA, and IMRT are suitable for treating brain metastases in SRS/SRT due to their improved dose conformity and target coverage while minimizing dose to healthy tissues.
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Affiliation(s)
- Zyad A Tawfik
- Radiological Sciences Department, Inaya Medical Colleges, Riyadh, Saudi Arabia
- Physics Department, Faculty of Science, Assiut University, Assiut, Egypt
| | | | - Khaled M El Shahat
- Radiation Oncology Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed A Hussein
- Physics Department, Faculty of Science, Assiut University, Assiut, Egypt
| | - Mostafa Al Etreby
- Oncology Department, Dr. Soliman Fakeeh Hospital | DSFH, Jeddah, Saudi Arabia
- Oncology Department, Cairo University Hospital, Cairo, Egypt
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González-Virla B, Vargas-Ortega G, Romero-Gameros CA. Radiotherapy and Mortality in Pituitary Adenomas. Arch Med Res 2023; 54:102900. [PMID: 37940504 DOI: 10.1016/j.arcmed.2023.102900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 09/13/2023] [Accepted: 10/19/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Pituitary adenomas (PA), comprising 10-20% of intracranial tumors, are classified as functioning and non-functioning and are further divided by size. Non-functioning tumors cause mechanical symptoms while functioning ones result in hormonal hypersecretion syndromes. Initial treatment involves surgery, with medical treatment for prolactinomas. Radiotherapy (RT) is employed as an adjuvant treatment, with various modalities including conventional, stereotactic radiosurgery (SRS), and fractionated stereotactic RT (FSRT). Although effective, RT is associated with complications and toxicities such as hypopituitarism, optic neuritis, secondary CNS tumors, and neurocognitive deficits. AIM Describe the information on mortality from radiotherapy as treatment of functioning PA. METHODS A PubMed search spanning 2000-2017 was conducted for articles on pituitary RT. RESULTS Conventional RT entails high-energy radiation over multiple sessions, while SRS delivers precise high doses in a single session. FSRT offers enhanced precision using a linear accelerator, delivering multiple doses. Optic structure proximity and tumor volume dictate RT modality. Studies have shown SRS and FSRT's efficacy in tumor and endocrine control, with variable risks and complications. Mortality rates in pituitary adenomas treated with RT have been evaluated, revealing complexities. Acromegaly, associated with increased mortality due to cerebrovascular disease, may result from RT. Irradiation of non-functioning pituitary macroadenomas also elevates cerebrovascular risk, while radiotherapy-induced hypopituitarism is associated with increased cardiovascular mortality. RT-induced damage is attributed to microvascular lesions and arteriolar changes. CONCLUSION Modern techniques mitigate complications, and although safer, long-term studies are needed. Multidisciplinary evaluation guides the treatment decision, optimizing efficacy and minimizing risk, ultimately improving the patient's quality of life.
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Affiliation(s)
- Baldomero González-Virla
- Endocrinology Service, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico.
| | - Guadalupe Vargas-Ortega
- Endocrinology Service, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Carlos Alfonso Romero-Gameros
- Otorrinolaringology Service, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Luzzi S, Giotta Lucifero A, Rabski J, Kadri PAS, Al-Mefty O. The Party Wall: Redefining the Indications of Transcranial Approaches for Giant Pituitary Adenomas in Endoscopic Era. Cancers (Basel) 2023; 15:cancers15082235. [PMID: 37190164 DOI: 10.3390/cancers15082235] [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: 02/20/2023] [Revised: 03/14/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
The evolution of endoscopic trans-sphenoidal surgery raises the question of the role of transcranial surgery for pituitary tumors, particularly with the effectiveness of adjunct irradiation. This narrative review aims to redefine the current indications for the transcranial approaches for giant pituitary adenomas in the endoscopic era. A critical appraisal of the personal series of the senior author (O.A.-M.) was performed to characterize the patient factors and the tumor's pathological anatomy features that endorse a cranial approach. Traditional indications for transcranial approaches include the absent pneumatization of the sphenoid sinus; kissing/ectatic internal carotid arteries; reduced dimensions of the sella; lateral invasion of the cavernous sinus lateral to the carotid artery; dumbbell-shaped tumors caused by severe diaphragm constriction; fibrous/calcified tumor consistency; wide supra-, para-, and retrosellar extension; arterial encasement; brain invasion; coexisting cerebral aneurysms; and separate coexisting pathologies of the sphenoid sinus, especially infections. Residual/recurrent tumors and postoperative pituitary apoplexy after trans-sphenoidal surgery require individualized considerations. Transcranial approaches still have a critical role in giant and complex pituitary adenomas with wide intracranial extension, brain parenchymal involvement, and the encasement of neurovascular structures.
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Affiliation(s)
- Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Alice Giotta Lucifero
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
- Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy
| | - Jessica Rabski
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Paulo A S Kadri
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Medical School, Federal University of Mato Grosso do Sul, Campo Grande 79070-900, Brazil
| | - Ossama Al-Mefty
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Abstract
A small subset of lactotroph adenomas is resistant to dopamine agonists (DA) and can also demonstrate aggressive or even malignant behavior. The implicated mechanisms are not clearly defined. Management can be challenging and requires a multidisciplinary approach. In DA resistant prolactinomas, switching to another DA could be the first option to consider. Further strategies include surgery and radiotherapy used alone or in combination. In cases of aggressive or malignant prolactinomas, temozolomide could be offered. Immune checkpoint inhibitors have been also recently proposed as an alternative approach. The place of other treatments (e.g., metformin, selective estrogen modulators, somatostatin analogues, tyrosine kinase inhibitors, inhibitors of mammalian target of rapamycin and peptide radio-receptor therapy) remains to be carefully assessed.
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Affiliation(s)
- Sandrine A Urwyler
- Institute of Metabolism and Systems Research (ISMR), College of Medical and Dental Sciences, University of Birmingham, IBR Tower, Level 2, Birmingham, B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research (ISMR), College of Medical and Dental Sciences, University of Birmingham, IBR Tower, Level 2, Birmingham, B15 2TT, UK.
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK.
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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8
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Bianchi A, Chiloiro S, Giampietro A, Gaudino S, Calandrelli R, Mazzarella C, Caldarella C, Rigante M, Gessi M, Lauretti L, De Marinis L, Olivi A, Pontecorvi A, Doglietto F. Multidisciplinary management of difficult/aggressive growth-hormone pituitary neuro-endocrine tumors. Front Endocrinol (Lausanne) 2023; 14:1123267. [PMID: 37206441 PMCID: PMC10189777 DOI: 10.3389/fendo.2023.1123267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/13/2023] [Indexed: 05/21/2023] Open
Abstract
Growth Hormone-secreting adenomas exhibits variable biological behavior and heterogeneous natural history, ranging from small adenomas and mild disease, to invasive and aggressive neoplasms with more severe clinical picture. Patients not cured or controlled after neurosurgical and first-generation somatostatin receptor ligands (SRL) therapy could require multiple surgical, medical and/or radiation treatments to achieve disease control. To date, no clinical, laboratory, histopathological, or neuroradiological markers are able to define the aggressiveness or predict the disease prognosis in patients with acromegaly. Therefore, the management of these patients requires careful evaluation of laboratory assessments, diagnostic criteria, neuroradiology examinations, and neurosurgical approaches to choose an effective and patient-tailored medical therapy. A multidisciplinary approach is particularly useful in difficult/aggressive acromegaly to schedule multimodal treatment, which includes radiation therapy, chemotherapy with temozolomide and other, recent emerging treatments. Herein, we describe the role of the different members of the multidisciplinary team according to our personal experience; a flow-chart for the therapeutic approach of difficult/aggressive acromegaly patients is proposed.
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Affiliation(s)
- Antonio Bianchi
- Pituitary Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Endocrinology and Diabetes Unit, Department of Medical and Surgical Translational Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Sabrina Chiloiro
- Pituitary Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Endocrinology and Diabetes Unit, Department of Medical and Surgical Translational Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- *Correspondence: Sabrina Chiloiro,
| | - Antonella Giampietro
- Pituitary Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Endocrinology and Diabetes Unit, Department of Medical and Surgical Translational Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Simona Gaudino
- Radiology and Neuroradiology Unit, Department of Imaging, Radiation Therapy and Hematology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Rosalinda Calandrelli
- Radiology and Neuroradiology Unit, Department of Imaging, Radiation Therapy and Hematology, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Ciro Mazzarella
- Radiation Therapy Unit, Department of Imaging, Radiation Therapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Carmelo Caldarella
- Nuclear Medicine Unit, Department of Imaging, Radiation Therapy and Hematology, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Mario Rigante
- Department of Aging, Neurological, Orthopedic and Head-Neck Sciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Marco Gessi
- Neuropathology Unit, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Pathology Unit of Head and Neck, Lung and Endocrine Systems, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Liverana Lauretti
- Neurosurgery Unit, Department of Neurosciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Neurosurgery Unit, Department of Neurosciences, Catholic University School of Medicine, Rome, Italy
| | - Laura De Marinis
- Pituitary Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Endocrinology and Diabetes Unit, Department of Medical and Surgical Translational Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Alessandro Olivi
- Neurosurgery Unit, Department of Neurosciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Neurosurgery Unit, Department of Neurosciences, Catholic University School of Medicine, Rome, Italy
| | - Alfredo Pontecorvi
- Pituitary Unit, Department of Medical and Surgical Sciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Endocrinology and Diabetes Unit, Department of Medical and Surgical Translational Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Francesco Doglietto
- Neurosurgery Unit, Department of Neurosciences, Fondazione Policlinico Universitario Agostino Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Neurosurgery Unit, Department of Neurosciences, Catholic University School of Medicine, Rome, Italy
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Stereotactic radiosurgery with or without surgical resection for pituitary adenoma: Insights from the National Cancer Database. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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Even-Zohar N, Greenman Y. Current medical treatment and perspective in gonadotroph tumors. Best Pract Res Clin Endocrinol Metab 2022; 36:101685. [PMID: 35871905 DOI: 10.1016/j.beem.2022.101685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Gonadotroph cell adenoma is the most common clinically nonfunctioning pituitary adenoma; and is pathologically defined by immunopositivity for SF-1, GATA2 and ER-α. Most tumors also stain for follicle stimulating hormone and luteinizing hormone β-subunits, but are usually hormonally silent and discovered incidentally or due to local mass effects. Complete transsphenoidal resection should be attempted when surgery is indicated. Post-surgical treatment can include radiation of the tumor remnant and medical treatment. Among medical treatments, dopamine agonists show the best evidence for preventing the need for recurrent surgery or radiation, and should be considered in patients with relatively bulky remnants or who have high risk features associated with tumor progression. Temozolomide is indicated for aggressive adenomas and carcinomas. Less well-established treatments include somatostatin receptor ligands, peptide receptor radionucleotide therapy and immunomodulatory agents.
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Affiliation(s)
- Naomi Even-Zohar
- Institute of Endocrinology, Diabetes, Metabolism, and Hypertension, Tel Aviv-Sourasky Medical Center, Israel.
| | - Yona Greenman
- Institute of Endocrinology, Diabetes, Metabolism, and Hypertension, Tel Aviv-Sourasky Medical Center, Israel; Sackler Faculty of Medicine, Tel Aviv University, Israel.
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11
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Fajardo-Montañana C, Villar R, Gómez-Ansón B, Brea B, Mosqueira AJ, Molla E, Enseñat J, Riesgo P, Cardona-Arboniés J, Hernando O. Recommendations for the diagnosis and radiological follow-up of pituitary neuroendocrine tumours. ENDOCRINOL DIAB NUTR 2022; 69:744-761. [PMID: 36428207 DOI: 10.1016/j.endien.2021.10.014] [Citation(s) in RCA: 1] [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: 08/04/2021] [Accepted: 10/01/2021] [Indexed: 06/16/2023]
Abstract
Pituitary neuroendocrine tumours (PitNETs) constitute a heterogeneous group of tumours with a gradually increasing incidence, partly accounted for by more sensitive imaging techniques and more extensive experience in neuroradiology in this regard. Although most PitNETs are indolent, some exhibit aggressive behaviour, and recurrence may be seen after surgical removal. The changes introduced in the WHO classification in 2017 and terminological debates in relation to neuroendocrine tumours warrant an update of the guidelines for the diagnosis, preoperative and postoperative management, and follow-up of response to treatment of PitNETs. This multidisciplinary document, an initiative of the Neuroendocrinology area of the Sociedad Española de Endocrinología y Nutrición [Spanish Society of Endocrinology and Nutrition] (SEEN), focuses on neuroimaging studies for the diagnosis, prognosis and follow-up of PitNETs. The basic requirements and elements that should be covered by magnetic resonance imaging are described, and a minimum radiology report to aid clinicians in treatment decision-making is proposed. This work supplements the consensus between the Neuroendocrinology area of the SEEN and the Sociedad Española de Anatomía Patológica [Spanish Society of Pathology] (SEAP) for the pathological study of PitNETs.
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Affiliation(s)
| | - Rocío Villar
- Departamento de Endocrinología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | - Beatriz Gómez-Ansón
- Neurorradiología, Departamento de Radiodiagnóstico, Hospital Universitari Sant Pau, Barcelona, Spain
| | - Beatriz Brea
- Departamento de Radiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Antonio Jesús Mosqueira
- Departamento de Radiología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
| | - Enrique Molla
- Departamento de Radiología, Hospital Universitario de la Ribera, Alcira, Valencia, Spain
| | - Joaquín Enseñat
- Departamento de Neurocirugía, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Pedro Riesgo
- Departamento de Neurocirugía, Hospital Universitario de la Ribera, Alcira, Valencia, Spain
| | - Jorge Cardona-Arboniés
- Departamento de Medicina Nuclear, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Ovidio Hernando
- Departamento de Oncología Radioterápica, Centro Integral Oncológico Clara Campal, Madrid, Spain
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12
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Baiano C, Somma T, Franca RA, Di Costanzo M, Scala MR, Cretella P, Esposito F, Cavallo LM, Cappabianca P, Solari D. Evolution in endoscopic endonasal approach for the management of hypothalamic–pituitary region metastasis: A single-institution experience. Front Oncol 2022; 12:975738. [PMID: 35965539 PMCID: PMC9366217 DOI: 10.3389/fonc.2022.975738] [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: 06/22/2022] [Accepted: 06/30/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionEndonasal endoscopic surgery has changed the treatment perspectives for different lesions of the hypothalamic–pituitary region. The metastases of the hypothalamic–pituitary region represent 0.4% of all intracranial metastatic tumors and account for only 1.8% of surgically managed pituitary lesions. The aim of tshis study is to describe a single-center institutional experience with 13 cases of hypothalamic–pituitary metastasis focused on presurgical workup, the evolution of the surgical technique, and postsurgical management according to our protocols, showing effects on progression-free and overall survival rates for this relatively uncommon location.Material and MethodsWe retrospectively reviewed the whole series of patients that received the endoscopic endonasal approach at the Division of Neurosurgery at the University of Naples “Federico II” undergoing surgery from January 1997 to December 2021. We identified 13 cases whose pathology reports revealed a metastatic lesion. Statistical analysis was performed to determine the Kaplan–Meier survival function and assess for log-rank differences in survival based on gender, surgical treatment, and postoperative therapy (p-value < 0.02*).ResultsThe pathology report disclosed lung adenocarcinoma (six cases, 46%), breast adenocarcinoma (two cases, 15.4%), clear cell renal carcinoma (one case, 7%), melanoma (one case, 7%), colorectal adenocarcinoma (one case, 7%), uterine cervix carcinoma (one case, 7%), and follicular thyroid carcinoma (one case, 7%). A standard endoscopic endonasal approach was performed in 10 patients (76.9%), while an extended endonasal procedure was performed in only three cases (23%). Biopsy was the surgical choice in five patients with infiltrative and invasive lesions and a poor performance status (38%), while in the cases where neurovascular decompression was necessary, a subtotal resection was achieved in five patients (38%) and partial resection in three patients (23%). Recovery of visual field defect was observed in six of seven patients with visual loss (85.7%), improvement of oculomotor nerve palsy occurred in four of seven patients with this defect (57.1%), while the impairment of oculomotor palsy was observed in three patients (42.9%). Visual function was stable in the other patients. The median progression-free survival and overall survival were 14 and 18 months, respectively. There were statistically significant differences in PFS and OS in patients who underwent adjuvant radiotherapy (p=0.019 is referred to OS and p=0.017 to PFS, respectively; p-value = 0.02).ConclusionsThe endoscopic endonasal approach is a viable approach for the management of hypothalamic–pituitary metastases as this surgery provides an adequate opportunity to obtain tissue sample and neurovascular decompression, both being crucial for continuing the integrated adjuvant therapy protocols.
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Affiliation(s)
- Cinzia Baiano
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
- *Correspondence: Cinzia Baiano,
| | - Teresa Somma
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Raduan Ahmed Franca
- Pathology Section, Department of Advanced Biomedical Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Marianna Di Costanzo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Maria Rosaria Scala
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Pasquale Cretella
- Pathology Section, Department of Advanced Biomedical Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Felice Esposito
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Luigi Maria Cavallo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Paolo Cappabianca
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
| | - Domenico Solari
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, Università degli Studi di Napoli “Federico II”, Naples, Italy
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13
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Chew CH, Chen JC, Hung SK, Wu TH, Lee MS, Chiou WY, Chen LC, Lin HY. Clinical outcomes of benign brain tumors treated with single fraction LINAC-based stereotactic radiosurgery: Experience of a single institute. Tzu Chi Med J 2022; 34:462-472. [PMID: 36578643 PMCID: PMC9791860 DOI: 10.4103/tcmj.tcmj_260_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/25/2021] [Accepted: 01/14/2022] [Indexed: 12/31/2022] Open
Abstract
Objectives Accelerator-based stereotactic radiosurgery (SRS) is a noninvasive and effective treatment modality widely used for benign brain tumors. This study aims to report 20-year treatment outcomes in our institute. Materials and Methods From May 2001 to December 2020, 127 patients treated with LINAC-based single-fraction SRS for their benign brain lesions were included. A neurosurgeon and two radiation oncologists retrospectively reviewed all data. Computed tomography (CT) simulation was performed after head-frame fixation under local anesthesia. All planning CT images were co-registered and fused with gadolinium-enhanced magnetic resonance imaging taken within 3 months for lesions targeting and critical organs delineation. The marginal dose was prescribed at 60%-90% isodose lines, respectively, to cover ≥95% planning target volume. Outcome evaluations included clinical tumor control rate (TCR), defined as the need for salvage therapy, and radiological response, defined as no enlargement of >2 cm in the maximal diameter. Overall survival (OS) and adverse reaction (defined according to CTCAE 5.0) were also analyzed. Results The present study included 76 female and 51 male patients for analysis. The median age was 59 years (range, 20-88 years). Their diagnoses were vestibular schwannoma (VS, n = 54), nonvestibular cranial nerve schwannoma (n = 6), meningioma (n = 50), and pituitary adenoma (n = 17). Totally 136 lesions were treated in a single fraction, predominantly skull base tumors, accounting for 69.1%. Median and mean follow-up duration was 49 and 61 months (range, 1-214 months), Overall TCR was 92.9%. The 5-year disease-specific TCR for VS, nonvestibular schwannoma, meningioma, and pituitary adenoma were 97.4%, 91.7%, 93.8%, and 83.3%. Salvage therapy was indicated for eight patients at 4-110 months after SRS. Among symptomatic patients, post-SRS symptom(s) was improved, stable, and worse in 68.2%, 24.3%, and 3.6%, respectively. Radiological response rate for 111 evaluable patients was 94.6% (shrinkage, 28.8%; stable, 65.8%). OS was 96.1% without treatment-related mortality. One patient with post-SRS cranial nerve injury (0.8%, involving the trigeminal nerve, grade 2 toxicities). No grade 3-4 acute or late toxicity was found. Conclusion Our results suggested that LINAC-based SRS effectively controls tumor growth and tumor-related neurological symptoms for patients with benign brain tumors. SRS is less aggressive, associated with low neurological morbidity and no mortality. Continuous follow-up is indicated to conclude longer outcomes.
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Affiliation(s)
- Chia-Hui Chew
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Jin-Cherng Chen
- Department of Neurosurgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Shih-Kai Hung
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Tsung-Hsien Wu
- Department of Neurosurgery, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
| | - Moon-Sing Lee
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Wen-Yen Chiou
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Liang-Cheng Chen
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Hon-Yi Lin
- Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan,School of Medicine, Tzu Chi University, Hualien, Taiwan,Institute of Molecular Biology, National Chung Cheng University, Chiayi, Taiwan,Address for correspondence: Dr. Hon-Yi Lin, Department of Radiation Oncology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, 2, Min-Sheng Road, Dalin, Chiayi, Taiwan. E-mail:
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14
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Lee EJ, Lee JY, Kim JW, Phi JH, Kim YH, Kim SK, Chung HT, Wang KC, Kim DG. Dosimetric parameters associated with the long-term oncological outcomes of Gamma Knife surgery for sellar and parasellar tumors in pediatric patients. J Neurosurg Pediatr 2022; 29:150-158. [PMID: 34678777 DOI: 10.3171/2021.7.peds21312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors aimed to investigate the dosimetric parameter and the minimally required dose associated with long-term control of sellar and parasellar tumors after Gamma Knife surgery (GKS) in children. METHODS A retrospective analysis was performed on pediatric patients younger than 19 years of age who were diagnosed with sellar and parasellar tumors and received GKS at the authors' institution from 1998 to 2019. Cox proportional hazards regression analyses were used to investigate the dosimetric parameters associated with treatment outcome. The Kaplan-Meier method was used to analyze tumor control rates after GKS. RESULTS Overall, 37 patients with 40 sellar and parasellar tumors, including 22 craniopharyngiomas and 12 pituitary adenomas, had a mean follow-up of 85.8 months. The gross target volume was 0.05 cm3 to 15.28 cm3, and the mean marginal dose was 15.8 Gy (range 9.6-30.0 Gy). Ten patients experienced treatment failure at a mean of 28.0 ± 26.7 months. The actuarial 5- and 10-year tumor control rates were 79.0% and 69.8%, respectively. D98% was an independent predictive factor of tumor control (HR 0.846 [95% CI 0.749-0.956], p = 0.007), with a cutoff value of 11.5 Gy for the entire cohort and 10 Gy for the craniopharyngioma group. Visual deterioration occurred in 2 patients with the maximum point dose of 10.1 Gy and 10.6 Gy to the optic apparatus. CONCLUSIONS In pediatric patients, D98% was a reliable index of the minimum required dose for long-term control of sellar and parasellar tumors after GKS. The optimal D98% value for each tumor diagnosis needs to be elucidated in the future.
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Affiliation(s)
- Eun Jung Lee
- 1Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul
| | - Ji Yeoun Lee
- 1Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul
- 2Division of Pediatric Neurosurgery, Department of Neurosurgery, Seoul National University Children's Hospital, Seoul
- 3Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul
| | - Jin-Wook Kim
- 1Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul
| | - Ji Hoon Phi
- 1Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul
- 2Division of Pediatric Neurosurgery, Department of Neurosurgery, Seoul National University Children's Hospital, Seoul
| | - Yong Hwy Kim
- 1Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul
- 4Pituitary Center, Seoul National University Hospital, Seoul; and
| | - Seung-Ki Kim
- 1Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul
- 2Division of Pediatric Neurosurgery, Department of Neurosurgery, Seoul National University Children's Hospital, Seoul
| | - Hyun-Tai Chung
- 1Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul
| | - Kyu-Chang Wang
- 5Neuro-oncology Clinic, National Cancer Center, Goyang, Republic of Korea
| | - Dong Gyu Kim
- 1Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul
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15
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Dissaux G, Josset S, Thillays F, Lucia F, Bourbonne V, Pradier O, Pasquier D, Biau J. Radiotherapy of benign intracranial tumours. Cancer Radiother 2021; 26:137-146. [PMID: 34953692 DOI: 10.1016/j.canrad.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
We present the updated recommendations of the French Society for Radiation Oncology on benign intracranial tumours. Most of them are meningiomas, vestibular schwannomas, pituitary adenomas, craniopharyngiomas, and glomus tumours. Some grow very slowly, and can be observed without specific treatment, especially if they are asymptomatic. Symptomatic or growing tumours are treated by surgery, which is the reference treatment. When surgery is not possible, due to the location of the lesion, or general conditions, radiotherapy can be applied, as it is if there is a postoperative growing residual tumour, or a local relapse. Indications have to be discussed at a multidisciplinary panel, with precise evaluation of the benefit and risks of the treatments. The techniques to be used are the most modern ones, as multimodal imaging and image-guided radiation therapy. Stereotactic treatments, using fractionated or single doses depending on the size or the location of the tumours, are commonly realized, to avoid as much a possible the occurrence of late side effects.
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Affiliation(s)
- G Dissaux
- Département de radiothérapie, CHRU Morvan, Latim, Inserm, UMR 1101, université de Brest, Isbam, UBO, UBL, 2, avenue Foch, 29200 Brest, France.
| | - S Josset
- Service de physique médicale, Institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - F Thillays
- Département de radiothérapie, Institut de cancérologie de l'Ouest, boulevard Jacques-Monod, 44805 Saint-Herblain, France
| | - F Lucia
- Département de radiothérapie, CHRU Morvan, Latim, Inserm, UMR 1101, université de Brest, Isbam, UBO, UBL, 2, avenue Foch, 29200 Brest, France
| | - V Bourbonne
- Département de radiothérapie, CHRU Morvan, Latim, Inserm, UMR 1101, université de Brest, Isbam, UBO, UBL, 2, avenue Foch, 29200 Brest, France
| | - O Pradier
- Département de radiothérapie, CHRU Morvan, Latim, Inserm, UMR 1101, université de Brest, Isbam, UBO, UBL, 2, avenue Foch, 29200 Brest, France
| | - D Pasquier
- Département universitaire de radiothérapie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59000 Lille, France; Centre de recherche en informatique, signal et automatique de Lille (Cristal) UMR 9189, université de Lille, 59000 Lille, France
| | - J Biau
- Département de radiothérapie, centre Jean-Perrin, 58, rue Montalembert, 63011 Clermont-Ferrand, France; Inserm, U1240 Imost, université Clermont-Auvergne, 63011 Clermont-Ferrand, France
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16
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Fajardo-Montañana C, Villar R, Gómez-Ansón B, Brea B, Mosqueira AJ, Molla E, Enseñat J, Riesgo P, Cardona-Arboniés J, Hernando O. Recomendaciones sobre el diagnóstico y seguimiento radiológico de los tumores neuroendocrinos hipofisarios. ENDOCRINOL DIAB NUTR 2021. [DOI: 10.1016/j.endinu.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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Ho HW, Yang CC, Lin HM, Chen HY, Huang CC, Wang SC, Lin YW. The new SRS/FSRT technique HyperArc for benign brain lesions: a dosimetric analysis. Sci Rep 2021; 11:21029. [PMID: 34702859 PMCID: PMC8548509 DOI: 10.1038/s41598-021-00381-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
To evaluate the potential benefit of HyperArc (HA) fractionated stereotactic radiotherapy (FSRT) for the benign brain lesion. Sixteen patients with a single deep-seated, centrally located benign brain lesion treated by CyberKnife (CK, G4 cone-based model) were enrolled. Treatment plans for HA with two different optimization algorithms (SRS NTO and ALDO) and coplanar RapidArc (RA) were generated for each patient to meet the corresponding treatment plan criteria. These four FSRT treatment plans were divided into two groups—the homogeneous delivery group (HA-SRS NTO and coplanar RA) and the inhomogeneous delivery group (HA-ALDO and cone-based CK)—to compare for dosimetric outcomes. For homogeneous delivery, the brain V5, V12, and V24 and the mean brainstem dose were significantly lower with the HA-SRS NTO plans than with the coplanar RA plans. The conformity index, high and intermediate dose spillage, and gradient radius were significantly better with the HA-SRS NTO plans than with the coplanar RA plans. For inhomogeneous delivery, the HA-ALDO exhibited superior PTV coverage levels to the cone-based CK plans. Almost all the doses delivered to organs at risk and dose distribution metrics were significantly better with the HA-ALDO plans than with the cone-based CK plans. Good dosimetric distribution makes HA an attractive FSRT technique for the treatment of benign brain lesions.
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Affiliation(s)
- Hsiu-Wen Ho
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Chieh Yang
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Pharmacy, Chia-Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Hsiu-Man Lin
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Hsiao-Yun Chen
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Radiation Oncology, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chun-Chiao Huang
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Shih-Chang Wang
- Department of Radiation Oncology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Wei Lin
- Department of Radiation Oncology, Kaohsiung Veterans General Hospital, No.386, Dazhong 1st Rd., Zuoying Dist., Kaohsiung City, 813414, Taiwan.
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18
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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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19
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Hug EB, Pelak M, Frank SJ, Fossati P. A Review of Particle Therapy for Skull Base Tumors: Modern Considerations and Future Directions. Int J Part Ther 2021; 8:168-178. [PMID: 34285944 PMCID: PMC8270106 DOI: 10.14338/ijpt-20-00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/24/2021] [Indexed: 11/23/2022] Open
Abstract
Skull base tumors constitute one of the established indications for particle therapy, specifically proton therapy. However, a number of prognostic factors, practical clinical management issues, and the emerging role of carbon ion therapy remain subjects of active clinical investigation. This review summarizes these topics, assesses the present status, and reflects on future research directions focusing on the management of chordomas, one of the most aggressive skull base tumors. In addition, the role of particle therapy for benign tumors of the skull base, including pituitary adenoma and acoustic neuroma, is reviewed.
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Affiliation(s)
- Eugen B Hug
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Maciej Pelak
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
| | - Steven J Frank
- MD Anderson Cancer Center, Division of Radiation Oncology, Houston, TX, USA
| | - Piero Fossati
- MedAustron Ion Therapy Center, Wiener Neustadt, Austria
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Abstract
External radiation therapy (RT) directed to the pituitary gland is generally recommended in patients with Cushing's disease (CD) as adjuvant to transsphenoidal surgery, among other second-line therapies offered to patients with residual or recurrent hypercortisolism (i.e., medical treatment, repeat surgery or bilateral adrenalectomy). RT is effective for the control of tumor growth, even in invasive tumors and in Nelson's syndrome. Progress in radiation stereotactic techniques lead to improved tumor targeting and radiation delivery, thus sparing the adjacent brain structures. Stereotactic RT is associated with a 55-65% rate of cortisol normalization after several months to a few years and potentially with a lower risk of long-term complications, compared with conventional RT. Cortisol-lowering medical therapy is recommended while awaiting the radiation effects. Hypopituitarism is the most frequent side-effect, damage to optic or cranial nerves or second brain tumors are rarely reported. This review presents the updates in the efficacy and safety of the stereotactic radiation techniques in CD patients. Practical points which should be considered by the clinician before recommending RT are also presented.
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Affiliation(s)
- Monica Livia Gheorghiu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania; National Institute of Endocrinology C.I. Parhon, Bucharest, Romania.
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21
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Alhilali LM, Little AS, Yuen KCJ, Lee J, Ho TK, Fakhran S, White WL. Early postoperative MRI and detection of residual adenoma after transsphenoidal pituitary surgery. J Neurosurg 2021; 134:761-770. [PMID: 32032952 DOI: 10.3171/2019.11.jns191845] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current practice guidelines recommend delayed (≥ 3 months after operation) postoperative MRI after transsphenoidal surgery for pituitary adenomas, although this practice defers obtaining important information, such as the presence of a residual adenoma, that might influence patient management during the perioperative period. In this study, the authors compared detection of residual adenomas by means of early postoperative (EPO) MRI (< 48 hours postsurgery) with both surgeon intraoperative assessment and late postoperative (LPO) MRI at 3 months. METHODS Adult patients who underwent microscopic transsphenoidal surgery for pituitary adenomas with MRI preoperatively, < 48 hours after the operation, 3 months postoperatively, and yearly for 4 years were included. The presence or absence of residual tumor was assessed intraoperatively by a single surgeon and postoperatively by 2 neuroradiologists blinded to the intraoperative assessment and other postoperative imaging studies. The presence of residual tumor was confirmed by reresection, tumor growth on imaging, or hormonal evidence. Interreader reliability was calculated at each imaging time point. Specificity, sensitivity, positive predictive value, and negative predictive value for EPO and LPO imaging and intraoperative assessment were determined. RESULTS In total, 102 consecutive patients who underwent microscopic transsphenoidal resection of a pituitary adenoma were included. Eighteen patients (18%) had confirmed residual tumors (12 confirmed by tumor growth, 5 by surgery, and 1 by biochemical evidence of persistent disease). Interreader reliability for detecting residual tumor on EPO MRI was almost perfect (κ = 0.88) and significantly higher than that for LPO MRI (κ = 0.69, p = 0.03). EPO MRI was highly specific for residual tumor (98%), a finding similar to that for intraoperative assessment (99%, p = 0.60) and significantly higher than that for LPO MRI (81%, p < 0.001). Notably, EPO MRI was significantly more sensitive for residual tumor (100%) than both intraoperative assessment (78%, p = 0.04) and LPO MRI (78%, p = 0.04). EPO MRI had a 100% negative predictive value and was used to find 4 residual tumors that were not identified intraoperatively. Residual tumors found on EPO MRI allowed for reresection during the same hospitalization for 3 patients. CONCLUSIONS EPO MRI after transsphenoidal pituitary surgery can be reliably interpreted and has greater sensitivity for detecting residual tumor than intraoperative assessment and LPO MRI. This result challenges current guidelines stating that delayed postoperative imaging is preferable to early imaging. Pituitary surgeons should consider performing EPO MRI either in addition to or instead of delayed imaging.
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Affiliation(s)
| | | | - Kevin C J Yuen
- 3Neurology and Barrow Neuroendocrinology Clinic, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Jae Lee
- Departments of1Neuroradiology
| | | | - Saeed Fakhran
- 4Department of Radiology, Radiology Partners, Banner Health and Hospital System, Phoenix, Arizona
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22
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Minniti G, Tini P. Watch the Mass, Save the Gland (Radiation Therapy Perhaps Later). Int J Radiat Oncol Biol Phys 2021; 109:653-654. [PMID: 32105743 DOI: 10.1016/j.ijrobp.2020.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 01/21/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Giuseppe Minniti
- Radiation Oncology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Viale Bracci, Siena, Italy; IRCCS Neuromed, Pozzilli (IS), Italy
| | - Paolo Tini
- Radiation Oncology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Viale Bracci, Siena, Italy
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23
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Lehrer EJ, Prabhu AV, Sindhu KK, Lazarev S, Ruiz-Garcia H, Peterson JL, Beltran C, Furutani K, Schlesinger D, Sheehan JP, Trifiletti DM. Proton and Heavy Particle Intracranial Radiosurgery. Biomedicines 2021; 9:31. [PMID: 33401613 PMCID: PMC7823941 DOI: 10.3390/biomedicines9010031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/23/2020] [Accepted: 12/30/2020] [Indexed: 12/25/2022] Open
Abstract
Stereotactic radiosurgery (SRS) involves the delivery of a highly conformal ablative dose of radiation to both benign and malignant targets. This has traditionally been accomplished in a single fraction; however, fractionated approaches involving five or fewer treatments have been delivered for larger lesions, as well as lesions in close proximity to radiosensitive structures. The clinical utilization of SRS has overwhelmingly involved photon-based sources via dedicated radiosurgery platforms (e.g., Gamma Knife® and Cyberknife®) or specialized linear accelerators. While photon-based methods have been shown to be highly effective, advancements are sought for improved dose precision, treatment duration, and radiobiologic effect, among others, particularly in the setting of repeat irradiation. Particle-based techniques (e.g., protons and carbon ions) may improve many of these shortcomings. Specifically, the presence of a Bragg Peak with particle therapy at target depth allows for marked minimization of distal dose delivery, thus mitigating the risk of toxicity to organs at risk. Carbon ions also exhibit a higher linear energy transfer than photons and protons, allowing for greater relative biological effectiveness. While the data are limited, utilization of proton radiosurgery in the setting of brain metastases has been shown to demonstrate 1-year local control rates >90%, which are comparable to that of photon-based radiosurgery. Prospective studies are needed to further validate the safety and efficacy of this treatment modality. We aim to provide a comprehensive overview of clinical evidence in the use of particle therapy-based radiosurgery.
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Affiliation(s)
- Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Arpan V. Prabhu
- Department of Radiation Oncology, UAMS Winthrop P. Rockefeller Cancer Institute University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA;
| | - Kunal K. Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Stanislav Lazarev
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (E.J.L.); (K.K.S.); (S.L.)
| | - Henry Ruiz-Garcia
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Jennifer L. Peterson
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Chris Beltran
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - Keith Furutani
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
| | - David Schlesinger
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22903, USA; (D.S.); (J.P.S.)
| | - Jason P. Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, VA 22903, USA; (D.S.); (J.P.S.)
| | - Daniel M. Trifiletti
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL 32224, USA; (H.R.-G.); (J.L.P.); (C.B.); (K.F.)
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24
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Combs SE, Baumert BG, Bendszus M, Bozzao A, Brada M, Fariselli L, Fiorentino A, Ganswindt U, Grosu AL, Lagerwaard FL, Niyazi M, Nyholm T, Paddick I, Weber DC, Belka C, Minniti G. ESTRO ACROP guideline for target volume delineation of skull base tumors. Radiother Oncol 2020; 156:80-94. [PMID: 33309848 DOI: 10.1016/j.radonc.2020.11.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/13/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE For skull base tumors, target definition is the key to safe high-dose treatments because surrounding normal tissues are very sensitive to radiation. In the present work we established a joint ESTRO ACROP guideline for the target volume definition of skull base tumors. MATERIAL AND METHODS A comprehensive literature search was conducted in PubMed using various combinations of the following medical subjects headings (MeSH) and free-text words: "radiation therapy" or "stereotactic radiosurgery" or "proton therapy" or "particle beam therapy" and "skull base neoplasms" "pituitary neoplasms", "meningioma", "craniopharyngioma", "chordoma", "chondrosarcoma", "acoustic neuroma/vestibular schwannoma", "organs at risk", "gross tumor volume", "clinical tumor volume", "planning tumor volume", "target volume", "target delineation", "dose constraints". The ACROP committee identified sixteen European experts in close interaction with the ESTRO clinical committee who analyzed and discussed the body of evidence concerning target delineation. RESULTS All experts agree that magnetic resonance (MR) images with high three-dimensional spatial accuracy and tissue-contrast definition, both T2-weighted and volumetric T1-weighted sequences, are required to improve target delineation. In detail, several key issues were identified and discussed: i) radiation techniques and immobilization, ii) imaging techniques and target delineation, and iii) technical aspects of radiation treatments including planning techniques and dose-fractionation schedules. Specific target delineation issues with regard to different skull base tumors, including pituitary adenomas, meningiomas, craniopharyngiomas, acoustic neuromas, chordomas and chondrosarcomas are presented. CONCLUSIONS This ESTRO ACROP guideline achieved detailed recommendations on target volume definition for skull base tumors, as well as comprehensive advice about imaging modalities and radiation techniques.
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Affiliation(s)
- Stephanie E Combs
- Department of Radiation Oncology, Technical University of Munich, Munich, Germany; Institute of Radiation Medicine, Department of Radiation Sciences, Helmholtz Zentrum München, Munich, Germany; German Cancer Consortium (DKTK) Partner Site (DKTK), Munich, Germany
| | - Brigitta G Baumert
- Institute of Radiation Oncology, Cantonal Hospital Graubuenden, Chur, Switzerland
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Germany
| | - Alessandro Bozzao
- Dipartimento NESMOS, Università Sapienza Roma, Azienda Ospedaliera Sant'Andrea, Rome, Italy
| | - Michael Brada
- Department of Radiation Oncology, Clatterbridge Cancer Centre NHS Foundation Trust, Bebington, United Kingdom
| | - Laura Fariselli
- Radiotherapy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alba Fiorentino
- Radiation Oncology Department, General Regional Hospital F. Miulli, Acquaviva delle fonti, Italy
| | - Ute Ganswindt
- Department of Therapeutic Radiology and Oncology, Medical University of Innsbruck, Innsbruck, Austria
| | - Anca L Grosu
- Department of Radiation Oncology, Medical Faculty, University of Freiburg, Freiburg, Germany; German Cancer Consortium (DKTK) Partner Site Freiburg, Germany
| | - Frank L Lagerwaard
- Department of Radiation Oncology, Amsterdam University Medical Centers, Location VUmc, The Netherlands
| | - Maximilian Niyazi
- German Cancer Consortium (DKTK) Partner Site (DKTK), Munich, Germany; Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Tufve Nyholm
- Department of Radiation Sciences, Radiation Physics, Umeå University, Umeå, Sweden
| | - Ian Paddick
- Queen Square Radiosurgery Centre, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | | | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy; IRCCS Neuromed, Pozzilli, Italy.
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25
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Lian X, Shen J, Gu Z, Yan J, Sun S, Hou X, You H, Xing B, Zhu H, Shen J, Zhang F. Intensity-modulated Radiotherapy for Pituitary Somatotroph Adenomas. J Clin Endocrinol Metab 2020; 105:5905930. [PMID: 32930785 DOI: 10.1210/clinem/dgaa651] [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: 06/29/2020] [Accepted: 09/11/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To summarize our experience in the treatment of pituitary somatotroph adenomas by fractionated intensity-modulated radiotherapy (IMRT), describe the treatment outcomes, and determine predictors. METHODS AND MATERIALS Patients with pituitary somatotroph adenoma treated by IMRT in our institution from August 2009 to January 2019 were reviewed. A total of 113 patients (37 male) were included in this study. The median age was 33 years (range 12-67 years). A total of 112 patients had not achieved complete remission after surgery, and 1 patient was treated by radiotherapy (RT) alone because she refused to surgery. The median growth hormone level was 8.6 ng/mL (range 2-186 ng/mL) and the median insulin-like growth factor (IGF)-1 level was 732 ng/mL (range 314-1485 ng/mL) pre-RT. The radiation doses to clinical target volume were usually 50-56 Gy in 25 to 30 fractions and to gross tumor volume were 60.2 Gy in 28 fractions while simultaneous integrated boost-IMRT used. After RT, the patients were followed up with endocrine testing every 6 to 12 months and magnetic resonance imaging annually. Endocrine complete remission was defined as a normal sex- and age-adjusted IGF-1 level without any pituitary suppressive medications. The outcomes including endocrine remission and new hypopituitarism after RT were recorded. The median follow-up time was 36 months (range 6-105.5 months). RESULTS The endocrine complete remission rates of IGF-1 at 1, 2, 3, and 5 years were 6%, 22.8%, 48.6%, and 74.3%, respectively. The median time to complete remission was 36.2 ± 3.8 months. The tumor control rate was 99% during the follow-up. The overall incidence of RT-induced hypopituitarism was 28.3% at the last follow-up. Univariate and multivariate analysis demonstrated that tumor sizes before RT, pre-RT IGF-1 level, and age significant predicted the endocrine remission. CONCLUSIONS IMRT is a highly effective treatment for pituitary somatotroph adenoma. Endocrine remission rate, tumor control rate, the median time to remission and hypopituitarism incidence are similar to stereotactic radiosurgery. Age and IGF-1 level before RT were significant predictive factors in endocrine remission.
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Affiliation(s)
- Xin Lian
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jing Shen
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhaoqi Gu
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Junfang Yan
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Shuai Sun
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiaorong Hou
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Hui You
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huijuan Zhu
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Shen
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Fuquan Zhang
- Department of Radiation Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Kim M, Kim HS, Kim HJ, Park JE, Park SY, Kim YH, Kim SJ, Lee J, Lebel MR. Thin-Slice Pituitary MRI with Deep Learning-based Reconstruction: Diagnostic Performance in a Postoperative Setting. Radiology 2020; 298:114-122. [PMID: 33141001 DOI: 10.1148/radiol.2020200723] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background Achieving high-spatial-resolution pituitary MRI is challenging because of the trade-off between image noise and spatial resolution. Deep learning-based MRI reconstruction enables image denoising with sharp edges and reduced artifacts, which improves the image quality of thin-slice MRI. Purpose To assess the diagnostic performance of 1-mm slice thickness MRI with deep learning-based reconstruction (DLR) (hereafter, 1-mm MRI+DLR) compared with 3-mm slice thickness MRI (hereafter, 3-mm MRI) for identifying residual tumor and cavernous sinus invasion in the evaluation of postoperative pituitary adenoma. Materials and Methods This single-institution retrospective study included 65 patients (mean age ± standard deviation, 54 years ± 10; 26 women) who underwent a combined imaging protocol including 3-mm MRI and 1-mm MRI+DLR for postoperative evaluation of pituitary adenoma between August and October 2019. Reference standards for correct diagnosis were established by using all available imaging resources, clinical histories, laboratory findings, surgical records, and pathology reports. The diagnostic performances of 3-mm MRI, 1-mm slice thickness MRI without DLR (hereafter, 1-mm MRI), and 1-mm MRI+DLR for identifying residual tumor and cavernous sinus invasion were evaluated by two readers and compared between the protocols. Results The performance of 1-mm MRI+DLR in the identification of residual tumor was comparable to that of 3-mm MRI (area under the receiver operating characteristic curve [AUC], 0.89-0.92 vs 0.85-0.89, respectively; P ≥ .09). In the identification of cavernous sinus invasion, the diagnostic performance of 1-mm MRI+DLR was higher than that of 3-mm MRI (AUC, 0.95-0.98 vs 0.83-0.87, respectively; P ≤ .02). Conventional 1-mm MRI (AUC, 0.82-0.83) showed comparable diagnostic performance to 3-mm MRI (AUC, 0.83-0.87) (P ≥ .38). With 1-mm MRI+DLR, residual tumor was diagnosed in 20 patients and cavernous sinus invasion was diagnosed in 14 patients, in whom these diagnoses were not made with 3-mm MRI. Conclusion In the postoperative evaluation of pituitary adenoma, 1-mm slice thickness MRI with deep learning-based reconstruction showed higher diagnostic performance than 3-mm slice thickness MRI in the identification of cavernous sinus invasion and comparable diagnostic performance to 3-mm slice thickness MRI in the identification of residual tumor. © RSNA, 2020 Online supplemental material is available for this article.
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Affiliation(s)
- Minjae Kim
- From the Department of Radiology and Research Institute of Radiology (M.K., H.S.K., H.J.K., J.E.P., S.J.K.), Department of Clinical Epidemiology and Biostatistics (S.Y.P.), and Department of Neurosurgery (Y.H.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, South Korea; GE Healthcare Korea, Seoul, Korea (J.L.); GE Healthcare Canada, Calgary, Canada (M.R.L.); and Department of Radiology, University of Calgary, Calgary, Canada (M.R.L.)
| | - Ho Sung Kim
- From the Department of Radiology and Research Institute of Radiology (M.K., H.S.K., H.J.K., J.E.P., S.J.K.), Department of Clinical Epidemiology and Biostatistics (S.Y.P.), and Department of Neurosurgery (Y.H.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, South Korea; GE Healthcare Korea, Seoul, Korea (J.L.); GE Healthcare Canada, Calgary, Canada (M.R.L.); and Department of Radiology, University of Calgary, Calgary, Canada (M.R.L.)
| | - Hyun Jin Kim
- From the Department of Radiology and Research Institute of Radiology (M.K., H.S.K., H.J.K., J.E.P., S.J.K.), Department of Clinical Epidemiology and Biostatistics (S.Y.P.), and Department of Neurosurgery (Y.H.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, South Korea; GE Healthcare Korea, Seoul, Korea (J.L.); GE Healthcare Canada, Calgary, Canada (M.R.L.); and Department of Radiology, University of Calgary, Calgary, Canada (M.R.L.)
| | - Ji Eun Park
- From the Department of Radiology and Research Institute of Radiology (M.K., H.S.K., H.J.K., J.E.P., S.J.K.), Department of Clinical Epidemiology and Biostatistics (S.Y.P.), and Department of Neurosurgery (Y.H.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, South Korea; GE Healthcare Korea, Seoul, Korea (J.L.); GE Healthcare Canada, Calgary, Canada (M.R.L.); and Department of Radiology, University of Calgary, Calgary, Canada (M.R.L.)
| | - Seo Young Park
- From the Department of Radiology and Research Institute of Radiology (M.K., H.S.K., H.J.K., J.E.P., S.J.K.), Department of Clinical Epidemiology and Biostatistics (S.Y.P.), and Department of Neurosurgery (Y.H.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, South Korea; GE Healthcare Korea, Seoul, Korea (J.L.); GE Healthcare Canada, Calgary, Canada (M.R.L.); and Department of Radiology, University of Calgary, Calgary, Canada (M.R.L.)
| | - Young-Hoon Kim
- From the Department of Radiology and Research Institute of Radiology (M.K., H.S.K., H.J.K., J.E.P., S.J.K.), Department of Clinical Epidemiology and Biostatistics (S.Y.P.), and Department of Neurosurgery (Y.H.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, South Korea; GE Healthcare Korea, Seoul, Korea (J.L.); GE Healthcare Canada, Calgary, Canada (M.R.L.); and Department of Radiology, University of Calgary, Calgary, Canada (M.R.L.)
| | - Sang Joon Kim
- From the Department of Radiology and Research Institute of Radiology (M.K., H.S.K., H.J.K., J.E.P., S.J.K.), Department of Clinical Epidemiology and Biostatistics (S.Y.P.), and Department of Neurosurgery (Y.H.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, South Korea; GE Healthcare Korea, Seoul, Korea (J.L.); GE Healthcare Canada, Calgary, Canada (M.R.L.); and Department of Radiology, University of Calgary, Calgary, Canada (M.R.L.)
| | - Joonsung Lee
- From the Department of Radiology and Research Institute of Radiology (M.K., H.S.K., H.J.K., J.E.P., S.J.K.), Department of Clinical Epidemiology and Biostatistics (S.Y.P.), and Department of Neurosurgery (Y.H.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, South Korea; GE Healthcare Korea, Seoul, Korea (J.L.); GE Healthcare Canada, Calgary, Canada (M.R.L.); and Department of Radiology, University of Calgary, Calgary, Canada (M.R.L.)
| | - Marc R Lebel
- From the Department of Radiology and Research Institute of Radiology (M.K., H.S.K., H.J.K., J.E.P., S.J.K.), Department of Clinical Epidemiology and Biostatistics (S.Y.P.), and Department of Neurosurgery (Y.H.K.), University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-Gu, Seoul 05505, South Korea; GE Healthcare Korea, Seoul, Korea (J.L.); GE Healthcare Canada, Calgary, Canada (M.R.L.); and Department of Radiology, University of Calgary, Calgary, Canada (M.R.L.)
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Kotecha R, Yomo S, Suh JH. Response to letter regarding "Stereotactic radiosurgery for nonfunctioning pituitary adenomas: meta-analysis and International Society of Stereotactic Radiosurgery (ISRS) practice opinion". Neuro Oncol 2020; 22:1402-1403. [PMID: 32621485 DOI: 10.1093/neuonc/noaa132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Shoji Yomo
- Division of Radiation Oncology, Aizawa Comprehensive Cancer Center, Aizawa Hospital, Matsumoto, Japan
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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28
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Lee WJ, Cho KR, Choi JW, Kong DS, Seol HJ, Nam DH, Lee JI. Gamma Knife Radiosurgery as a Primary Treatment for Nonfunctioning Pituitary Adenoma Invading the Cavernous Sinus. Stereotact Funct Neurosurg 2020; 98:371-377. [PMID: 32937617 DOI: 10.1159/000508737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/11/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Surgical resection of nonfunctioning pituitary adenoma (NFPA) invading the cavernous sinus (CS) remains a challenging and significant factor associated with incomplete resection. The residual tumor in CS is usually treated with adjuvant stereotactic radiosurgery (SRS), but there is little information concerning SRS as an initial treatment for CS-invading NFPA. In this study, we investigated the tumor control rate and clinical outcomes of the patients who received primary gamma knife radiosurgery (GKRS) for CS-invading NFPA. METHODS This was a single-institute retrospective analysis of 11 patients. CS invasion of tumor was categorized using the modified Knosp grading system. The median tumor volume and maximal diameter were 1.6 cm3 (range 0.4-6.5) and 17.2 mm (range 11.6-23.3), respectively. The median clinical follow-up period was 48.5 months (range 16.4-177.8). The median prescription dose at tumor margin was 15 Gy (range 11-25) and median prescription isodose was 50% (range 45-50). The maximum radiation dose to optic chiasm and optic nerve were 7.2 Gy (range 3.4-9.2) and 7.5 Gy (range 4.5-11.5), respectively. RESULTS Tumor control was achieved in all patients. The median tumor volume and maximal diameter at last follow-up were 0.4 cm3 (range 0.1-2.3) and 11.4 mm (range 4.7-19.5), respectively. The median volume reduction rate was 52% (range 33-88). Six patients showed downgrading of modified Knosp grade after GKRS. No patients developed GKRS-related complications such as hypopituitarism or visual disturbance. CONCLUSIONS SRS may be an alternative primary treatment option for CS-invading NFPA if there is no urgent and absolute indication for surgery such as optic apparatus compression.
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Affiliation(s)
- Won Jae Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyung-Rae Cho
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea,
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Kara M, Güdük M, Samanci Y, Yilmaz M, Şengöz M, Peker S. Gamma knife radiosurgery in patients with Cushing's disease: Comparison of aggressive pituitary corticotroph tumor versus corticotroph adenoma. Clin Neurol Neurosurg 2020; 197:106151. [PMID: 32882541 DOI: 10.1016/j.clineuro.2020.106151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/06/2020] [Accepted: 08/09/2020] [Indexed: 10/23/2022]
Abstract
Aggressive pituitary corticotroph tumors causing Cushing's disease are rare, and there is limited data about their clinical management. Here, we aimed to report our long-term experience with gamma knife radiosurgery (GKRS) as adjuvant treatment in patients with residual or recurrent pituitary corticotroph tumors. This retrospective study included 45 adult patients (M/F, 7/38; mean age, 40.2 ± 13.1 years) with residual tumor or recurrence after initially successful surgical resection. Single-session GKRS was performed in all patients. Tumors with a Ki-67 value higher than 3 % and radiologic invasion to surrounding tissues were classified as aggressive tumor group. Clinical, hormonal and radiological findings were compared between the aggressive (n = 10) and non-aggressive adenoma (n = 35) groups. Following GKRS, tumor volumes were significantly reduced in both groups. The mean time to hormonal remission in the non-aggressive group was significantly shorter than in the aggressive group (23.5 ± 6.3 vs 33.0 ± 5.0 month, respectively, p < 0.05). New-onset hypopituitarism was identified in only seven patients (15 %) after GKRS in the whole cohort. The present study introduces several essential findings about aggressive corticotroph tumors. First, aggressive behavior tends to occur more frequently in male subjects. Second, time to GKRS was significantly shorter in the aggressive group. Moreover, a tumor volume ≥2 cm3 may be associated with clinical aggressiveness in corticotroph tumors. In conclusion, we suggest that early adjuvant GKRS is an effective treatment option in aggressive pituitary corticotroph tumors.
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Affiliation(s)
- Müjdat Kara
- Acıbadem University School of Medicine, Department of Endocrinology, İstanbul, Turkey.
| | - Mustafa Güdük
- Acıbadem University School of Medicine, Department of Neurosurgery, İstanbul, Turkey
| | - Yavuz Samanci
- Koç University School of Medicine, Department of Neurosurgery, İstanbul, Turkey
| | - Meltem Yilmaz
- Acıbadem University School of Medicine, Medical Biotechnology Program, İstanbul, Turkey
| | - Meriç Şengöz
- Acıbadem University School of Medicine, Department of Radiation Oncology, İstanbul, Turkey
| | - Selçuk Peker
- Koç University School of Medicine, Department of Neurosurgery, İstanbul, Turkey
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Minniti G, Paolini S, Rea MLJ, Isidori A, Scaringi C, Russo I, Osti MF, Cavallo L, Esposito V. Stereotactic reirradiation with temozolomide in patients with recurrent aggressive pituitary tumors and pituitary carcinomas. J Neurooncol 2020; 149:123-130. [PMID: 32632895 DOI: 10.1007/s11060-020-03579-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 06/29/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To evaluate the efficacy of a second course of fractionated stereotactic radiotherapy (re-SRT) and temozolomide (TMZ) as salvage treatment option in patients with aggressive pituitary tumors (APTs) and pituitary carcinomas (PCs). PATIENTS AND METHODS Twenty-one patients with recurrent or progressive APTs (n = 17) and PCs (n = 4) who received combined TMZ and re-SRT, 36 Gy/18fractions or 37.5 Gy/15fractions, were retrospectively evaluated. TMZ was given at a dose of 75 mg/m2 given concurrently to re-SRT, and then 150-200 mg/m2/day for 5 days every 4 weeks or 50 mg/m2 daily for 12 months. Local control (LC) and overall survival (OS) were calculated from the time of re-SRT by Kaplan-Meier method. RESULTS With a median follow-up of 27 months (range 12-58 months), 2-year and 4-year LC rates were 73% and 65%, respectively; 2-year and 4-year survival rates were 82% and 66%, respectively. A complete response was achieved in 2 and partial response in 11 patients. Six patients recurred with a median time to progression of 14 months. O(6)-Methylguanine-DNA methyltransferase (MGMT) status and tumor volume emerged as prognostic factors. Grade 3 radiation-related toxicities occurred in 3 (14%) patients. Grade 2 or 3 hematologic toxicities during chemotherapy occurred in 8 (38%) patients. CONCLUSION Re-SRT and TMZ is a safe treatment offering high LC in patients with progressive APTs and PCs. The potential advantages of combined chemoradiation as up-front or salvage treatment need to be explored in prospective trials.
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Affiliation(s)
- Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, 53100, Siena, Italy. .,IRCCS Neuromed, Pozzilli, IS, Italy.
| | | | - Marie Lise Jaffrain Rea
- Biotechnological and Applied Clinical Sciences Department, University of L'Aquila, L'Aquila, Italy
| | - Andrea Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Claudia Scaringi
- UPMC Hillman Cancer Center, San Pietro Hospital FBF, Rome, Italy
| | - Ivana Russo
- UPMC Hillman Cancer Center, Villa Maria, Mirabella, AV, Italy
| | | | - Luigi Cavallo
- Division of Neurosurgery, Università degli Studi di Napoli "Federico II", Naples, Italy
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31
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Ramos-Prudencio R, Pérez-Álvarez SI, Flores-Balcazar CH, de León-Alfaro MA, Herrera-González JA, Elizalde-Cabrera J, Rubalcava-Ortega J, Espinoza-Alvarado L, Balderrama-Ibarra RI. Radiotherapy for the treatment of pituitary adenomas: A dosimetric comparison of three planning techniques. Rep Pract Oncol Radiother 2020; 25:586-593. [PMID: 32508534 PMCID: PMC7264003 DOI: 10.1016/j.rpor.2020.04.020] [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: 08/22/2019] [Revised: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022] Open
Abstract
AIM Our goal was to compare conformal 3D (C3D) radiotherapy (RT), modulated intensity RT (IMRT), and volumetric modulated arc therapy (VMAT) planning techniques in treating pituitary adenomas. BACKGROUND RT is important for managing pituitary adenomas. Treatment planning advances allow for higher radiation dosing with less risk of affecting organs at risk (OAR). MATERIALS AND METHODS We conducted a 5-year retrospective review of patients with pituitary adenoma treated with external beam radiation therapy (C3D with flattening filter, flattening filter-free [FFF], IMRT, and VMAT). We compared dose-volume histogram data. For OARs, we recorded D2%, maximum, and mean doses. For planning target volume (PTV), we registered V95%, V107%, D95%, D98%, D50%, D2%, minimum dose, conformity index (CI), and homogeneity index (HI). RESULTS Fifty-eight patients with pituitary adenoma were included. Target-volume coverage was acceptable for all techniques. The HI values were 0.06, IMRT; 0.07, VMAT; 0.08, C3D; and 0.09, C3D FFF (p < 0.0001). VMAT and IMRT provided the best target volume conformity (CI, 0.64 and 0.74, respectively; p < 0.0001). VMAT yielded the lowest doses to the optic pathway, lens, and cochlea. The position of the neck in extreme flexion showed that it helps in planning mainly with VMAT by allowing only one arc to be used and achieving the desired conformity, decreasing the treatment time, while allowing greater protection to the organs of risk using C3D, C3DFFF. CONCLUSIONS Our results confirmed that EBRT in pituitary adenomas using IMRT, VMAT, C3D, C3FFF provide adequate coverage to the target. VMAT with a single arc or incomplete arc had a better compliance with desired dosimetric goals, such as target coverage and normal structures dose constraints, as well as shorter treatment time. Neck extreme flexion may have benefits in treatment planning for better preservation of organs at risk. C3D with extreme neck flexion is an appropriate treatment option when other treatment techniques are not available.
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Key Words
- C3D, conformal three-dimensional radiotherapy
- CFRT, conventional fractionated radiotherapy
- CI, conformity index
- CT, computed tomography
- CTV, clinical target volume
- Conformal radiotherapy
- DVH, dose-volume histogram
- EBRT, external beam radiation therapy
- ESAPI, Eclipse Scripting Application Programming Interface
- FF, flattening filter
- FFF, flattening filter free
- GTV, gross tumor volume
- HI, homogeneity index
- IMRT
- IMRT, modulated intensity radiotherapy
- MRI, magnetic resonance imaging
- OAR, organs at risk
- PTV, planning target volume
- Pituitary adenomas
- RION, radiation-induced neuropathy
- RT, radiotherapy
- SRS, stereotactic radiosurgery
- VMAT
- VMAT, volumetric modulated arc therapy
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Affiliation(s)
- Rubi Ramos-Prudencio
- Department of Radiotherapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Sandra Ileana Pérez-Álvarez
- Department of Radiotherapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Christian Haydée Flores-Balcazar
- Department of Radiotherapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Mayra Angélica de León-Alfaro
- Department of Radiotherapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - José Alfredo Herrera-González
- Division of Radiotherapy, Instituto Nacional de Cancerología, 22 San Fernando Ave, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Jonathan Elizalde-Cabrera
- Division of Radiotherapy, Instituto Nacional de Cancerología, 22 San Fernando Ave, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Johnatan Rubalcava-Ortega
- Department of Neuroimaging, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Lissett Espinoza-Alvarado
- Department of Neuroimaging, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Ricardo Iván Balderrama-Ibarra
- Department of Radiotherapy, Instituto Mexicano Del Seguro Social (IMSS), Centro Médico Nacional de Occidente, Universidad de Guadalajara, Independencia Oriente, Guadalajara 44340, Mexico
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AlMalki MH, Ahmad MM, Brema I, AlDahmani KM, Pervez N, Al-Dandan S, AlObaid A, Beshyah SA. Contemporary Management of Clinically Non-functioning Pituitary Adenomas: A Clinical Review. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2020; 13:1179551420932921. [PMID: 32636692 PMCID: PMC7318824 DOI: 10.1177/1179551420932921] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 12/25/2022]
Abstract
Non-functioning pituitary adenomas (NFPAs) are benign pituitary tumours that constitute about one-third of all pituitary adenomas. They typically present with symptoms of mass effects resulting in hypopituitarism, visual symptoms, or headache. Most NFPAs are macroadenomas (>1 cm in diameter) at diagnosis that can occasionally grow quite large and invade the cavernous sinus causing acute nerve compression and some patients may develop acute haemorrhage due to pituitary apoplexy. The progression from benign to malignant pituitary tumours is not fully understood; however, genetic and epigenetic abnormalities may be involved. Non-functioning pituitary carcinoma is extremely rare accounting for only 0.1% to 0.5 % of all pituitary tumours and presents with cerebrospinal, meningeal, or distant metastasis along with the absence of features of hormonal hypersecretion. Pituitary surgery through trans-sphenoidal approach has been the treatment of choice for symptomatic NFPAs; however, total resection of large macroadenomas is not always possible. Recurrence of tumours is frequent and occurs in 51.5% during 10 years of follow-up and negatively affects the overall prognosis. Adjuvant radiotherapy can decrease and prevent tumour growth but at the cost of significant side effects. The presence of somatostatin receptor types 2 and 3 (SSTR3 and SSTR2) and D2-specific dopaminergic receptors (D2R) within NFPAs has opened a new perspective of medical treatment for such tumours. The effect of dopamine agonist from pooled results on patients with NFPAs has emerged as a very promising treatment modality as it has resulted in reduction of tumour size in 30% of patients and stabilization of the disease in about 58%. Despite the lack of long-term studies on the mortality, the available limited evidence indicates that patients with NFPA have higher standardized mortality ratios (SMR) than the general population, with women particularly having higher SMR than men. Older age at diagnosis and higher doses of glucocorticoid replacement therapy are the only known predictors for increased mortality.
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Affiliation(s)
- Mussa H AlMalki
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia.,Faculty of Medicine, King Saud Bin Abdulaziz University of Health Sciences, Riyadh, Saudi Arabia
| | - Maswood M Ahmad
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Imad Brema
- Obesity, Endocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Khaled M AlDahmani
- Department of Endocrinology, Tawam Hospital in Affiliation with Johns Hopkins Medicine, Al Ain, United Arab Emirates.,College of Medicine and Health Sciences (CMHS), UAE University, Al Ain, United Arab Emirates
| | - Nadeem Pervez
- Department of Radiation Oncology, Tawam Hospital in affiliation with Johns Hopkins Medicine, Al Ain, United Arab Emirates
| | - Sadeq Al-Dandan
- Department of Histopathology, Maternity and Children Hospital, Al-Hasa, Saudi Arabia
| | - Abdullah AlObaid
- Department of Neurosurgery, National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Salem A Beshyah
- Department of Medicine, Dubai Medical College, Dubai, United Arab Emirates.,Department of Endocrinology, Mediclinic Airport, Abu Dhabi, United Arab Emirates
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Singh R, Didwania P, Lehrer EJ, Sheehan D, Sheehan K, Trifiletti DM, Sheehan JP. Stereotactic radiosurgery for acromegaly: an international systematic review and meta-analysis of clinical outcomes. J Neurooncol 2020; 148:401-418. [PMID: 32506372 DOI: 10.1007/s11060-020-03552-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/30/2020] [Indexed: 02/01/2023]
Abstract
INTRODUCTION We performed a systematic review and meta-analysis of clinical outcomes for patients with acromegaly treated with stereotactic radiosurgery (SRS). METHODS Primary outcomes were 5- and 10-year endocrine remission (ER) and endocrine control (EC). Secondary outcomes were 10-year radiographic local control (LC), visual toxicity, and hypopituitarism rates. Weighted random effects meta-analyses using the DerSimonian and Laird methods were conducted to characterize and compare effect sizes. Mixed effects regression models were used to examine correlations between potential prognostic factors and primary and secondary outcomes. RESULTS In total, 1533 patients across 20 published studies with acromegaly treated with SRS were included. At 5-years, estimated ER and EC rates were 43.2% (95% CI 31.7-54.6%) and 55.0% (95% CI 27.6-82.4%), respectively. At 10-years, estimated ER and EC rates were 56.9% (95% CI 47.5-66.4%) and 69.7% (95% CI 47.7-91.8%), respectively. The estimated 10-year LC rate was 92.8% (95% CI 83.0-100%). Visual toxicity and hypopituitarism following SRS were estimated to be 2.7% (95% CI 1.3-4.2%) and 26.8% (95% CI 16.9-36.7%), respectively. Every 1 Gy increase in margin prescription dose beyond 17 Gy was estimated to result in a 0.41% increased risk of visual toxicity (p = 0.03). No prognostic factors were associated with EC, ER, LC, or hypopituitarism. CONCLUSIONS SRS was well-tolerated in the management of pituitary acromegaly resulting in gradually improving ER and EC rates over time that approached 60% and 70%. SRS-related visual loss is an uncommon treatment-related side effect, and patient-specific clinical decision making remains critical.
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Affiliation(s)
- Raj Singh
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, VA, USA
| | - Prabhanjan Didwania
- Rady School of Management, University of California at San Diego, San Diego, CA, USA
| | - Eric J Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Darrah Sheehan
- Department of Neurosurgery, University of Virginia, School of Medicine, Box 800212, Charlottesville, VA, 22903, USA
| | - Kimball Sheehan
- Department of Neurosurgery, University of Virginia, School of Medicine, Box 800212, Charlottesville, VA, 22903, USA
| | | | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, School of Medicine, Box 800212, Charlottesville, VA, 22903, USA.
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Khattab MH, Sherry AD, Xu MC, Kelly P, Anderson JL, Luo G, Chambless LB, Cmelak AJ, Attia A. Stereotactic Radiosurgery and Hypofractionated Stereotactic Radiotherapy for Nonfunctioning Pituitary Adenoma. J Neurol Surg B Skull Base 2020; 82:e51-e58. [PMID: 34306917 DOI: 10.1055/s-0040-1710518] [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: 10/04/2019] [Accepted: 03/14/2020] [Indexed: 10/24/2022] Open
Abstract
Objectives Hypofractionated stereotactic radiotherapy (HSRT) in two to five fractions may offer patients with large nonfunctioning pituitary adenomas (NFPAs) with chiasm involvement a safe and effective treatment over a single week. However, little has been reported regarding this novel approach. Design We compared the feasibility, outcomes, and toxicity of single-fraction stereotactic radiosurgery and HSRT. Setting This study was conducted at a tertiary academic referral center. Participants After approval by the institutional review board, we performed a retrospective cohort study of patients treated at our institution with stereotactic radiosurgery (SRS) and HSRT for NFPA. Selection for SRS or HSRT was based on clinicopathologic factors including tumor size and cavernous sinus invasion at the discretion of the treating physician. Main Outcome Measures Local control, endocrinopathy, and radiation-associated toxicity were evaluated by binary logistic regression and Cox's proportional hazards regression. Results A total of 45 patients with mean follow-up of 5 years were enrolled including 26 patients treated by HSRT with mean follow-up of 3 years and 19 patients treated by SRS with median follow-up of 6 years. Clinicopathologic characteristics were balanced between cohorts. Local failure at last follow-up was 5% in the SRS cohort and 8% in the HSRT cohort, and rates of post-SRS endocrinopathy were similar between each cohort. Late complications including radionecrosis, visual deficit, and secondary malignancy were minimal in either cohort. Conclusions HSRT is an appropriate treatment strategy for patients with NFPAs, particularly for optic pathway preservation in the setting of large tumors with chiasm involvement. Further studies are needed to optimize fractionated approaches and patient selection.
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Affiliation(s)
- Mohamed H Khattab
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alexander D Sherry
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Mark C Xu
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Patrick Kelly
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Joshua L Anderson
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Lola B Chambless
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Anthony J Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, United States.,Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Byun J, Kim JH, Kim YH, Cho YH, Hong SH, Kim CJ. Thyroid-Stimulating Hormone-Secreting Pituitary Adenomas : Single Institutional Experience of 14 Consecutive Cases. J Korean Neurosurg Soc 2020; 63:495-503. [PMID: 32146779 PMCID: PMC7365277 DOI: 10.3340/jkns.2019.0169] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 10/06/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Thyroid-stimulating hormone (TSH)-secreting pituitary adenoma (PA) is an extremely rare functioning form of PA that accounts for 0.7-2% of all such cases. The previously reported outcomes of the surgical removal of TSH-PA are poor. Owing to its extremely low incidence, most available reports on TSH-PA are case reports or small case series. Thus, we investigated the clinical and endocrinological outcomes of surgically treated TSH-PA through our institutional series. METHODS We retrospectively reviewed 14 consecutive cases of surgically treated TSH-PA, focusing on the clinical, radiological, surgical, and endocrinological data. RESULTS There were seven male (50%) and seven female (50%) patients. The mean age was 42.5 years (range, 19-63). The mean tumor size was 16.6 mm (range, 4-30). Optic chiasm compression was noted in six patients (42.9%), and no patient showed cavernous sinus invasion. Thirteen of 14 patients (92.8%) underwent transnasal transsphenoidal approach (TSA), and one patient underwent TSA followed by transcranial approach for residual tumor removal. Thirteen of 14 patients (92.8%) showed endocrinological remission; all patients who experienced remission showed subnormal levels of TSH (<0.4 μU/mL) on postoperative day 2. Recurrence occurred in two patients (14.2%). One patient underwent subsequent revision transnasal TSA for recurrent tumor removal, and the other patient underwent gamma knife radiosurgery for recurrence. CONCLUSION Surgical treatment showed excellent surgical outcomes. The TSH level in the immediate postoperative period may be a predictor for endocrinological remission.
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Affiliation(s)
- Joonho Byun
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Hoon Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Hyun Cho
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seok Ho Hong
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Jin Kim
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Treutwein M, Steger F, Loeschel R, Koelbl O, Dobler B. The influence of radiotherapy techniques on the plan quality and on the risk of secondary tumors in patients with pituitary adenoma. BMC Cancer 2020; 20:88. [PMID: 32013920 PMCID: PMC6998093 DOI: 10.1186/s12885-020-6535-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 01/13/2020] [Indexed: 12/20/2022] Open
Abstract
Background This planning study compares different radiotherapy techniques for patients with pituitary adenoma, including flatness filter free mode (FFF), concerning plan quality and secondary malignancies for potentially young patients. The flatness filter has been described as main source of photon scatter. Material and methods Eleven patients with pituitary adenoma were included. An Elekta Synergy™ linac was used in the treatment planning system Oncentra® and for the measurements. 3D plans, IMRT, and VMAT plans and non-coplanar varieties were considered. The plan quality was evaluated regarding homogeneity, conformity, delivery time and dose to the organs at risk. The secondary malignancy risk was calculated from dose volume data and from measured dose to the periphery using different models for carcinoma and sarcoma risk. Results The homogeneity and conformity were nearly unchanged with and without flattening filter, neither was the delivery time found substantively different. VMAT plans were more homogenous, conformal and faster in delivery than IMRT plans. The secondary cancer risk was reduced with FFF both in the treated region and in the periphery. VMAT plans resulted in a higher secondary brain cancer risk than IMRT plans, but the risk for secondary peripheral cancer was reduced. Secondary sarcoma risk plays a minor role. No advantage was found for non-coplanar techniques. The FFF delivery times were not shortened due to additional monitor units needed and technical limitations. The risk for secondary brain cancer seems to depend on the irradiated volume. Secondary sarcoma risk is much smaller than carcinoma risk in accordance to the results of the atomic bomb survivors. The reduction of the peripheral dose and resulting secondary malignancy risk for FFF is statistically significant. However, it is negligible in comparison to the risk in the treated region. Conclusion Treatments with FFF can reduce secondary malignancy risk while retaining similar quality as with flattening filter and should be preferred. VMAT plans show the best plan quality combined with lowest peripheral secondary malignancy risk, but highest level of second brain cancer risk. Taking this into account VMAT FFF seems the most advantageous technique for the treatment of pituitary adenomas with the given equipment.
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Affiliation(s)
- Marius Treutwein
- Department for radiotherapy, Regensburg University Medical Center, Regensburg, Germany.
| | - Felix Steger
- Department for radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Rainer Loeschel
- Faculty of computer science and mathematics, Ostbayerische Technische Hochschule, Regensburg, Germany
| | - Oliver Koelbl
- Department for radiotherapy, Regensburg University Medical Center, Regensburg, Germany
| | - Barbara Dobler
- Department for radiotherapy, Regensburg University Medical Center, Regensburg, Germany
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Albano L, Losa M, Flickinger J, Mortini P, Minniti G. Radiotherapy of Parasellar Tumours. Neuroendocrinology 2020; 110:848-858. [PMID: 32126559 DOI: 10.1159/000506902] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
Abstract
Parasellar tumours represent a wide group of intracranial lesions, both benign and malignant. They may arise from several structures located within the parasellar area or they may infiltrate or metastasize this region. The treatment of the tumours located in these areas is challenging because of their complex anatomical location and their heterogenous histology. It often requires a multimodal approach, including surgery, radiation therapy (RT), and medical therapy. Due to the proximity of critical structures and the risks of side effects related to the procedure, a successful surgical resection is often not achievable. Thus, RT plays a crucial role in the treatment of several parasellar tumours. Conventional fractionated RT and modern radiation techniques, like stereotactic radiosurgery and proton beam RT, have become a standard management option, in particular for cases with residual or recurrent tumours after surgery and for those cases where surgery is contraindicated. This review examines the role of RT in parasellar tumours analysing several techniques, outcomes and side effects.
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Affiliation(s)
- Luigi Albano
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
- Neuroimaging Research Unit, Division of Neuroscience, Institute of Experimental Neurology, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - John Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giuseppe Minniti
- Radiation Oncology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy,
- UPMC Hillman Cancer Center San Pietro Hospital, Rome, Italy,
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Tzikoulis V, Gkantaifi A, Alongi F, Tsoukalas N, Saraireh HH, Charalampakis N, Tzikoulis G, Andreou E, Tsapakidis K, Kardamakis D, Tsanadis K, Kyrgias G, Tolia M. Benign Intracranial Lesions - Radiotherapy: An Overview of Treatment Options, Indications and Therapeutic Results. Rev Recent Clin Trials 2019; 15:93-121. [PMID: 31713498 DOI: 10.2174/1574887114666191111100635] [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: 07/20/2019] [Revised: 10/14/2019] [Accepted: 10/26/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Radiation Therapy (RT) is an established treatment option for benign intracranial lesions. The aim of this study is to display an update on the role of RT concerning the most frequent benign brain lesions and tumors. METHODS Published articles about RT and meningiomas, Vestibular Schwannomas (VSs), Pituitary Adenomas (PAs), Arteriovenous Malformations (AVMs) and craniopharyngiomas were reviewed and extracted data were used. RESULTS In meningiomas RT is applied as an adjuvant therapy, in case of patientrefusing surgery or in unresectable tumors. The available techniques are External Beam RT (EBRT) and stereotactic ones such as Stereotactic Radiosurgery (SRS), Fractionated Stereotactic RT (FSRT), Intensity Modulated RT (IMRT) and proton-beam therapy. The same indications are considered in PAs, in which SRS and FSRT achieve excellent tumor control rate (92-100%), acceptable hormone remission rates (>50%) and decreased Adverse Radiation Effects (AREs). Upon tumor growth or neurological deterioration, RT emerges as alone or adjuvant treatment against VSs, with SRS, FSRT, EBRT or protonbeam therapy presenting excellent tumor control growth (>90%), facial nerve (84-100%), trigeminal nerve (74-99%) and hearing (>50%) preservation. SRS poses an effective treatment modality of certain AVMs, demonstrating a 3-year obliteration rate of 80%. Lastly, a combination of microsurgery and RT presents equal local control and 5-year survival rate (>90%) but improved toxicity profile compared to total resection in case of craniopharyngiomas. CONCLUSION RT comprises an effective treatment modality of benign brain and intracranial lesions. By minimizing its AREs with optimal use, RT projects as a potent tool against such diseases.
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Affiliation(s)
- Vasileios Tzikoulis
- School of Health Sciences, Faculty of Medicine, Biopolis, University of Thessaly, Larisa, 41500, Greece
| | - Areti Gkantaifi
- Radiotherapy Department, Interbalkan Medical Center, Thessaloniki, Greece
| | - Filippo Alongi
- Radiation Oncology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Nikolaos Tsoukalas
- Oncology Department, Veterans Hospital (NIMTS), 10-12 Monis Petraki Str., 115 21, Athens, Greece
| | - Haytham Hamed Saraireh
- Radiation Oncology Department, Jordanian Royal Medical Services, King Hussein Medical Center, King Abdullah II St 230, Amman, Jordan
| | | | - Georgios Tzikoulis
- Department of Biochemistry and Biotechnology, University of Thessaly, Biopolis, 41500, Larisa, Greece
| | - Emmanouil Andreou
- School of Health Sciences, Faculty of Medicine, Biopolis, University of Thessaly, Larisa, 41500, Greece
| | - Konstantinos Tsapakidis
- Department of Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, 41500, Larisa, Greece
| | - Dimitrios Kardamakis
- Department of Radiation Oncology, Medical School, University of Patras, 265 04, Patra, Greece
| | - Konstantinos Tsanadis
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
| | - George Kyrgias
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
| | - Maria Tolia
- Department of Radiotherapy/Radiation Oncology, Faculty of Medicine, School of Health Sciences, University of Thessaly, University Hospital of Larisa, Biopolis, 41500 Larisa, Greece
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Cyberknife stereotactic treatment of pituitary adenomas: A single center experience using different irradiation schemes and modalities. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2018.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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Abstract
Radiation therapy (RT) is an effective treatment for patients with either nonfunctioning or secreting pituitary adenomas unsuccessfully treated by surgery and/or medical therapy, resulting in local control of 90-95% at 5-10 years and variable normalization of hormonal hypersecretion for patients with GH-, ACTH-, and prolactin-secreting adenomas in the range of 40-80% at 5 years; however, its use has been limited because of concerns regarding potential late toxicity of radiation and delayed efficacy in normalization of hormone hypersecretion. In the last decades, there have been advances in all aspects of radiation treatment, including more accurate immobilization, imaging, treatment planning and dose delivery. RT has evolved with the development of highly conformal stereotactic techniques and new planning and dose delivery techniques, including intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT). All these new techniques allow precise and sharply focused radiation delivery reducing the dose to surrounding critical neurovascular and brain structures, and potentially limiting the long-term consequences of radiation treatments. In this review, we present a critical analysis of the more recent available literature on the use of RT in patients with both nonfunctioning and secreting pituitary adenomas, focussing particularly on the risk/benefit ratio of modern radiation techniques.
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Affiliation(s)
- Giuseppe Minniti
- Radiation Unit, UPMC Hillman Cancer Center, San Pietro Hospital, Rome, Italy.
| | - John Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Bashari WA, Senanayake R, Fernández-Pombo A, Gillett D, Koulouri O, Powlson AS, Matys T, Scoffings D, Cheow H, Mendichovszky I, Gurnell M. Modern imaging of pituitary adenomas. Best Pract Res Clin Endocrinol Metab 2019; 33:101278. [PMID: 31208872 DOI: 10.1016/j.beem.2019.05.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Decision-making in pituitary disease is critically dependent on high quality imaging of the sella and parasellar region. Magnetic resonance imaging (MRI) is the investigation of choice and, for the majority of patients, combined T1 and T2 weighted sequences provide the information required to allow surgery, radiotherapy (RT) and/or medical therapy to be planned and long-term outcomes to be monitored. However, in some cases standard clinical MR sequences are indeterminate and additional information is needed to help inform the choice of therapy for a pituitary adenoma (PA). This article reviews current recommendations for imaging of PA, examines the potential added value that alternative MR sequences and/or CT can offer, and considers how the use of functional/molecular imaging might allow definitive treatment to be recommended for a subset of patients who would otherwise be deemed unsuitable for (further) surgery and/or RT.
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Affiliation(s)
- Waiel A Bashari
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Russell Senanayake
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Antía Fernández-Pombo
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK; Division of Endocrinology and Nutrition, University Clinical Hospital of Santiago de Compostela, Spain
| | - Daniel Gillett
- Cambridge Endocrine Molecular Imaging Group, Department of Nuclear Medicine, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Olympia Koulouri
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Andrew S Powlson
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Tomasz Matys
- Cambridge Endocrine Molecular Imaging Group, Department of Radiology, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Daniel Scoffings
- Cambridge Endocrine Molecular Imaging Group, Department of Radiology, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Heok Cheow
- Cambridge Endocrine Molecular Imaging Group, Department of Nuclear Medicine, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK; Cambridge Endocrine Molecular Imaging Group, Department of Radiology, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Iosif Mendichovszky
- Cambridge Endocrine Molecular Imaging Group, Department of Nuclear Medicine, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK; Cambridge Endocrine Molecular Imaging Group, Department of Radiology, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| | - Mark Gurnell
- Cambridge Endocrine Molecular Imaging Group, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
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Plitt AR, El Ahmadieh TY, Aoun SG, Wardak Z, Barnett SL. Fractionated CyberKnife Stereotactic Radiotherapy for Perioptic Pituitary Adenomas. World Neurosurg 2019; 126:e1359-e1364. [PMID: 30902774 DOI: 10.1016/j.wneu.2019.03.102] [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: 02/03/2019] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) is the reference standard for radiotherapy for pituitary adenomas but has been limited to lesions with sufficient distance (i.e., >3 mm) from the optic apparatus. We used marginless, fractionated (i.e., 25-28 fractions) stereotactic radiotherapy and the CyberKnife to treat pituitary adenomas that were not eligible for SRS. We present the clinical outcomes, including local control, endocrine function, and toxicity from modern fractionated radiotherapy. METHODS A total of 53 patients were treated for pituitary adenomas within 3 mm of the optic apparatus. The primary endpoint was tumor control with the secondary endpoints of vision and pituitary function preservation and endocrine control in hormone-secreting tumors. RESULTS The tumor control rate as measured on magnetic resonance imaging as either stable or decreased in size was 98.1% (52 of 53) at a mean follow-up of 32.5 months (range, 3-77). All patients experienced preservation or improvement of their preexisting vision status. No change in pituitary function was noted in 52 of the 53 patients (98.1%). One patient experienced worsening of pituitary function secondary to pituitary apoplexy that occurred 4 months after treatment. The endocrine control rate in hormone-secreting tumors was 75% (6 of 8). CONCLUSIONS Marginless, fractionated CyberKnife radiotherapy demonstrated excellent local tumor control and endocrine control rates, comparable to those with SRS, with preservation of vision in patients with adenomas in close proximity to the optic pathway.
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Affiliation(s)
- Aaron R Plitt
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Zabi Wardak
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Samuel L Barnett
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Chhabra A, Schneider C, Chowdhary M, Diwanji TP, Mohindra P, Mishra MV. How Histopathologic Tumor Extent and Patterns of Recurrence Data Inform the Development of Radiation Therapy Treatment Volumes in Solid Malignancies. Semin Radiat Oncol 2018; 28:218-237. [PMID: 29933882 DOI: 10.1016/j.semradonc.2018.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The ability to deliver highly conformal radiation therapy using intensity-modulated radiation therapy and particle therapy provides for new opportunities to improve patient outcomes by reducing treatment-related morbidities following radiation therapy. By reducing the volume of normal tissue exposed to radiation therapy (RT), while also allowing for the opportunity to escalate the dose of RT delivered to the tumor, use of conformal RT delivery should also provide the possibility of expanding the therapeutic index of radiotherapy. However, the ability to safely and confidently deliver conformal RT is largely dependent on our ability to clearly define the clinical target volume for radiation therapy, which requires an in-depth knowledge of histopathologic extent of different tumor types, as well as patterns of recurrence data. In this article, we provide a comprehensive review of the histopathologic and radiographic data that provide the basis for evidence-based guidelines for clinical tumor volume delineation.
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Affiliation(s)
- Arpit Chhabra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Craig Schneider
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Mudit Chowdhary
- Department of Radiation Oncology, Rush University, Chicago, IL
| | - Tejan P Diwanji
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Pranshu Mohindra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD
| | - Mark V Mishra
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD.
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Outcome of partially irradiated recurrent nonfunctioning pituitary macroadenoma by gamma knife radiosurgery. J Neurooncol 2018; 139:767-775. [DOI: 10.1007/s11060-018-2925-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
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Eaton DJ, Lee J, Patel R, Millin AE, Paddick I, Walker C. Stereotactic radiosurgery for benign brain tumors: Results of multicenter benchmark planning studies. Pract Radiat Oncol 2018; 8:e295-e304. [PMID: 29884596 DOI: 10.1016/j.prro.2018.02.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 01/30/2018] [Accepted: 02/13/2018] [Indexed: 12/25/2022]
Abstract
PURPOSE Stereotactic radiosurgery (SRS) is strongly indicated for treatment of surgically inaccessible benign brain tumors. Various treatment platforms are available, but few comparisons have included multiple centers. As part of a national commissioning program, benchmark planning cases were completed by all clinical centers in the region. METHODS AND MATERIALS Four benign cases were provided, with images and structures predelineated, including intracanalicular vestibular schwannoma (VS), larger VS, skull base meningioma, and secreting pituitary adenoma. Centers were asked to follow their local practice, and plans were reviewed centrally using metrics for target coverage, selectivity, gradient falloff, and normal tissue sparing. RESULTS Sixty-eight plans were submitted using 18 different treatment platforms. Fourteen plans were subsequently revised following feedback, and review of 5 plans led to a restriction of service on 2 platforms (2 centers). Prescription doses were consistent for VS and meningioma submissions, but a wide range of doses were used for the pituitary case. All centers prioritized coverage, with the prescription isodose covering ≥95% of 78/82 target volumes. Lower values may be expected next to air cavities when using advanced algorithms, and in general may be acceptable for some benign lesions. Selectivity was much more variable, and in some cases this was combined with high gradient index and/or >1 mm margin, resulting in large volumes of normal tissue being irradiated. Normal tissue doses were more variable across linear accelerator (LINAC)-based plans than with Gamma Knife or CyberKnife, and dose spillage seemed independent of prescription isodose (inhomogeneity). This may reflect the variety of LINAC-based approaches represented or the necessary tradeoff between different objectives. CONCLUSIONS These benchmarking exercises have highlighted areas of different clinical practice and priorities and potential for improvement. The subsequent sharing of plan data and margin philosophies between the neurosurgery and oncology communities allowed for meaningful comparison between centers and their peers.
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Affiliation(s)
- David J Eaton
- National Radiotherapy Trials Quality Assurance group, Mount Vernon Hospital, Northwood, United Kingdom.
| | - Jonathan Lee
- National Radiotherapy Trials Quality Assurance group, Mount Vernon Hospital, Northwood, United Kingdom
| | - Rushil Patel
- National Radiotherapy Trials Quality Assurance group, Mount Vernon Hospital, Northwood, United Kingdom
| | | | - Ian Paddick
- Medical Physics Ltd, Reading, United Kingdom; Cromwell Hospital, London, United Kingdom
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Patibandla MR, Xu Z, Sheehan JP. Factors affecting early versus late remission in acromegaly following stereotactic radiosurgery. J Neurooncol 2018; 138:209-216. [PMID: 29417401 DOI: 10.1007/s11060-018-2792-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 02/01/2018] [Indexed: 11/25/2022]
Abstract
Stereotactic radiosurgery (SRS) is a well-established treatment modality for patients with acromegaly. Our previously published study demonstrated a median time to remission of 29 months. This study aims to identify factors affecting the timing of remission and also to quantify the rate of late remission. This is a retrospective analysis of acromegaly patients who underwent SRS between 1988 and 2016. Early and late remissions were defined based on our prior median remission time of 29 months. The median imaging and endocrine follow-ups are 66 and 104.8 months, respectively. Multivariate analysis was conducted to analyze factors leading to late remission. A total number of 157 patients, of those 102 (64.9%) patients achieved remission. of those 102 patients, 62 patients (60.7%) had remission in less than 29 months (early remission) whereas 40 patients (39.3%) achieved remission later than (late remission) 29 months. The two groups differed significantly in the time interval between the last resection and the first SRS (p = 0.040) whole sella radiosurgery (p = 0.025) or radiosurgery to the cavernous sinus (p = 0.041). Competing risk analysis showed the interval between resection and SRS was significantly longer in the late remission group (HR 1.013, 95% CI 1.004-1.02; p = 0.007). Fifty-one of 157 patients (32.5%) developed a new endocrine deficiency following SRS. Those with shorter time between resection and SRS were more likely to achieve early remission. While most patients achieve remission in less than 4 years, the latency of effect with SRS yields a small percentage of patients achieving remission beyond that time point.
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Affiliation(s)
- Mohana Rao Patibandla
- Department of Neurosurgery, University of Virginia, P.O. Box 800212, Charlottesville, VA, 22908, USA
| | - Zhiyuan Xu
- Department of Neurosurgery, University of Virginia, P.O. Box 800212, Charlottesville, VA, 22908, USA
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, P.O. Box 800212, Charlottesville, VA, 22908, USA.
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Abstract
The incidence of brain tumors in the elderly population has increased over the last few decades. Current treatment includes surgery, radiotherapy and chemotherapy, but the optimal management of older patients with brain tumors remains a matter of debate, since aggressive radiation treatments in this population may be associated with high risks of neurological toxicity and deterioration of quality of life. For such patients, a careful clinical status assessment is mandatory both for clinical decision making and for designing randomized trials to adequately evaluate the optimal combination of radiotherapy and chemotherapy. Several randomized studies have demonstrated the efficacy and safety of chemotherapy for patients with glioblastoma or lymphoma; however, the use of radiotherapy given in association with chemotherapy or as salvage therapy remains an effective treatment option associated with survival benefit. Stereotactic techniques are increasingly used for the treatment of patients with brain metastases and benign tumors, including pituitary adenomas, meningiomas and acoustic neuromas. Although no randomized trials have proven the superiority of SRS over other radiation techniques in older patients with brain metastases or benign brain tumors, data extracted from recent randomized studies and large retrospective series suggest that SRS is an effective approach in such patients associated with survival advantages and toxicity profile similar to those observed in young adults. Future trials need to investigate the optimal radiation techniques and dose/fractionation schedules in older patients with brain tumors with regard to clinical outcomes, neurocognitive function, and quality of life.
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Affiliation(s)
- Giuseppe Minniti
- Department of Neurological Sciences, IRCCS Neuromed, Via Atinense, Pozzilli, (IS), Italy. .,UPMC San Pietro FBF, Radiotherapy Center, Rome, Italy.
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Abstract
Purpose Treatment of acromegaly has undergone important progress in the last 20 years mainly due to the development of new medical options and advances in surgical techniques. Pituitary surgery is usually first-line therapy, and medical treatment is indicated for persistent disease, while radiation (RT) is often used as third-line therapy. The benefits of RT (tumor volume control and decreased hormonal secretion) are hampered by the long latency of the effect and the high risk of adverse effects. Stereotactic RT methods have been developed with the aim to provide more precise targeting of the tumor with better control of the radiation dose received by the adjacent brain structures. The purpose of this review is to present the updates in the efficacy and safety of pituitary RT in acromegalic patients, with an emphasis on the new stereotactic radiation techniques. Methods A systematic review was performed using PubMed and articles/abstracts and reviews detailing RT in acromegaly from 2000 to 2016 were included. Results Stereotactic radiosurgery and fractionated stereotactic RT (FSRT) for patients with persistent active acromegaly after surgery and/or during medical therapy provide comparable high rates of tumor control, i.e. stable or decrease in size of the tumor in 93-100% of patients at 5-10 years and endocrinological remission in 40-60% of patients at 5 years. Hypofractionated RT is an optimal option for tumors located near the optic structures, due to its lower toxicity for the optic nerves compared to single-dose radiosurgery. The rate of new hypopituitarism varies from 10 to 50% at 5 years and increases with the duration of follow-up. The risk for other radiation-induced complications is usually low (0-5% for new visual deficits, cranial nerves damage or brain radionecrosis and 0-1% for secondary brain tumors) and risk of stroke may be higher in FSRT. Conclusion Although the use of radiotherapy in patients with acromegaly has decreased with advances in medical treatments, it remains an effective treatment option after unsuccessful surgery and/or resistance or unavailability of medical therapy. Long-term studies evaluating secondary morbidity and mortality rate after the new stereotactic techniques are needed, in order to evaluate their potential brain-sparing effect.
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Affiliation(s)
- Monica Livia Gheorghiu
- C.I. Parhon" National Institute of Endocrinology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
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Gheorghiu ML, Fleseriu M. STEREOTACTIC RADIATION THERAPY IN PITUITARY ADENOMAS, IS IT BETTER THAN CONVENTIONAL RADIATION THERAPY? ACTA ENDOCRINOLOGICA-BUCHAREST 2017; 13:476-490. [PMID: 31149219 DOI: 10.4183/aeb.2017.476] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Pituitary radiotherapy (RT) has undergone important progress in the last decades due to the development of new stereotactic techniques which provide more precise tumour targeting with less overall radiation received by the adjacent brain structures. Pituitary surgery is usually first-line therapy in most patients with nonfunctioning (NFPA) and functioning adenomas (except for prolactinomas and large growth hormone (GH) secreting adenomas), while RT is used as second or third-line therapy. The benefits of RT (tumour volume control and, in functional tumours, decreased hormonal secretion) are hampered by the long latency of the effect and the potential side effects. This review presents the updates in the efficacy and safety of the new stereotactic radiation techniques in patients with NFPA, GH-, ACTH- or PRL-secreting pituitary adenomas. Methods A systematic review was performed using PubMed and articles/abstracts and reviews detailing RT in pituitary adenomas from 2000 to 2017 were included. Results Stereotactic radiosurgery (SRS) and fractionated stereotactic RT (FSRT) provide high rates of tumour control i.e. stable or decrease in tumour size, in all types of pituitary adenomas (median 92 - 98%) at 5 years. Endocrinological remission is however significantly lower: 44-52% in acromegaly, 54-64% in Cushing's disease and around 30% in prolactinomas at 5 years. The rate of new hypopituitarism varies from 10% to 50% at 5 years in all tumour types and as expected increases with the duration of follow-up (FU). The risk for other radiation-induced complications is usually low (0-5% for new visual deficits, cranial nerves damage or brain radionecrosis and extremely low for secondary brain tumours), however longer FU is needed to determine rates of secondary tumours. Notably, in acromegaly, there may be a higher risk for stroke with FSRT. Conclusion Stereotactic radiotherapy can be an effective treatment option for patients with persistent or recurrent pituitary adenomas after unsuccessful surgery (especially if residual tumour is enlarging) and/or resistance or unavailability of medical therapy. Comparison with conventional radiation therapy (CRT) is rather difficult, due to the substantial heterogeneity of the studies. In order to evaluate the potential brain-sparing effect of the new stereotactic techniques, suggested by the current data, long-term studies evaluating secondary morbidity and mortality are needed.
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Affiliation(s)
- M L Gheorghiu
- "Carol Davila" University of Medicine and Pharmacy, "C.I. Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - M Fleseriu
- Oregon Health & Science University, Departments of Medicine (Endocrinology) and Neurological Surgery, and Northwest Pituitary Center, Portland, USA
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Gheorghiu ML. NEWS IN ACROMEGALY. ACTA ENDOCRINOLOGICA-BUCHAREST 2017; 13:129-130. [PMID: 31149162 DOI: 10.4183/aeb.2017.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Recent updates on the epidemiology, diagnosis, complications and therapy in acromegaly have been published in the 1st 2017 issue of Pituitary journal. A review of 12 epidemiological studies published since 2004 shows that the prevalence of acromegaly ranges 2.8 - 13.7 cases per 100,000 people and the annual incidence rates range 0.2 - 1.1 cases/100,000 people. The median age at diagnosis ranges between 40.5 and 47 years. At the time of diagnosis, over 2/3 of the patients have macroadenomas. Acromegalic osteopathy is characterized by increase in bone turnover, alterations in bone microarchitecture and high risk of vertebral fractures, which occur in about 1/3 of acromegaly patients. Fractures may occur even in the presence of normal bone mineral density (BMD), in close relationship with male gender, hypogonadism, and active acromegaly. Following treatment for acromegaly in 48 patients, the mean trabecular bone score decreased by 3.0 (±7.0) %, whereas BMD at the lumbar spine increased by 3.2 (±4.9) % (both P<0.01). Alterations in trabecular bone architecture may explain the persistent fracture risk despite the increase in BMD after disease control. Stereotactic radiotherapy in acromegaly after surgery and/or during medical therapy provide tumor control in 93-100% of patients at 5-10 years and endocrinological remission in 40-60% of patients at 5 years, with a hypopituitarism rate of 10-50% at 5 years. Hypofractionated radiosurgery is an optimal option for tumors located near the optic structures, due to its lower toxicity for the optic nerves compared to single-dose radiosurgery. A dose-response model for visual pathway tolerance to SRS has been recently published.
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Affiliation(s)
- M L Gheorghiu
- "Carol Davila" University of Medicine and Pharmacy, "C.I. Parhon" National Institute of Endocrinology, Bucharest, Romania
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