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De Nigris Vasconcellos F, Vilela MAD, Garcia Torrico F, Scalise MA, Vargas VPS, Mendieta CD, Pichardo-Rojas P, Rosi MEA, Fleury LT, de Brito Rebelo ND, Benjamin C, Sheehan JP. Stereotactic radiosurgery for recurrent/residual nonfunctioning pituitary adenoma: a single-arm systematic review and meta-analysis. Acta Neurochir (Wien) 2024; 166:392. [PMID: 39356336 DOI: 10.1007/s00701-024-06296-4] [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: 07/06/2024] [Accepted: 09/28/2024] [Indexed: 10/03/2024]
Abstract
BACKGROUND Nonfunctioning pituitary adenomas (NFPAs) are a significant subtype of pituitary tumors, accounting for 30% of all pituitary tumors and 10-20% of intracranial tumors. The primary treatment for NFPAs is resection, but complete resection is often challenging due to the tumor's proximity to critical structures, leading to frequent recurrences. Stereotactic radiosurgery (SRS) has emerged as a viable treatment option for recurrent or residual NFPAs, but its long-term efficacy and safety profile require further investigation. METHODS This systematic review followed PRISMA guidelines and included studies published up to February 2024. We searched MEDLINE, Embase, and Cochrane databases for studies evaluating SRS for recurrent/residual NFPAs. Inclusion criteria focused on studies reporting outcomes and complications of SRS, while exclusion criteria omitted case reports, case series, and non-English studies. Data extracted included demographic details, dosimetry parameters, and follow-up durations. The risk of bias was assessed using the ROBINS-I tool, and statistical analyses were performed using single-arm meta-analyses. RESULTS A total of 24 studies involving 3,781 patients were included. The mean follow-up duration was 60 months. Tumor control was achieved in approximately 92.3% of patients. The risk of developing hypopituitarism post-SRS was 13.62%, while the risk for panhypopituitarism was 2.55%. New visual field deficits occurred in 3.94% of patients. Cranial nerve deficits were rare, with event rates below 1% for CN III, CN V, and CN VI. CONCLUSION SRS is effective in managing recurrent or residual NFPAs, achieving high tumor control rates. However, the risk of hypopituitarism remains a significant concern, necessitating regular endocrinological monitoring. While generally safe, the potential for new visual field deficits and other cranial nerve deficits must be considered. SRS remains a valuable treatment option, but clinicians should be aware of its potential complications.
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Affiliation(s)
| | | | | | | | | | - Cristian D Mendieta
- Universidad Mayor Real y Pontificia de San Francisco Xavier de Chuquisaca, Sucre, Bolivia
| | | | | | - Laura Tajara Fleury
- Pontifícia Universidade Católica de Campinas (PUC-CAMPINAS), Campinas, Brazil
| | | | | | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
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2
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Kara M, Yılmaz M, Şengöz M, Peker S. Hormonal and radiologic outcomes after gamma knife radiosurgery for nonfunctioning pituitary adenomas. Br J Neurosurg 2024; 38:486-492. [PMID: 33792443 DOI: 10.1080/02688697.2021.1903388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 02/02/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Gamma knife radiosurgery (GKRS) is an established treatment option for residual and recurrent nonfunctioning pituitary adenoma (NFPA). This investigation assessed hormonal and radiologic outcomes after adjuvant and primary GKRS for NFPAs. METHODS This retrospective study included 252 patients with NFPA who underwent GKRS at a single center between 2005 and 2016. GKRS was performed as adjuvant procedure in 216 (85.8%) patients and as primary procedure in 36 (14.2%) patients. Characteristics of these two groups were compared. RESULTS Mean age was comparable between adjuvant and primary GKRS groups (48.3 ± 12.6 vs. 52.2 ± 13.2 years, respectively, p > 0.05). Adjuvant GKRS and primary GKRS groups were similar in terms of the mean prescribed radiation dose and tumor volume (15.1 ± 2.7 vs. 15.3 ± 1.9 Gy and 4.2 ± 3.6 vs. 3.1 ± 2.5 cm3, respectively, p > 0.05 for both). The rate of endocrine deficiency during 5-year follow-up showed similar trend in adjuvant and primary GKRS groups (3.7%, 8.7%, and 14.8% vs. 5.6%, 13.9%, and 27.8% at first, third, and fifth year time points, respectively). Tumor control rates were also similar (98.6%, 96.3%, and 93% vs. 100%, 97.3%, and 94.5% at first, third, and fifth year time points, respectively). In both groups, tumor volume >5 cm3 was associated with higher rate of hypopituitarism and tumor progression. CONCLUSIONS GKRS was effective both as adjuvant and primary procedure in patients with NFPA. Radiation dose of ≤13.5 Gy was associated with lower tumor control rate and tumor volume >5 cm3 was associated with higher rates of hypopituitarism and tumor progression.
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Affiliation(s)
- Müjdat Kara
- Department of Endocrinology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Meltem Yılmaz
- Department of Medical Biotechnology, Acibadem University, Istanbul, Turkey
| | - Meriç Şengöz
- Department of Radiation Oncology, Acibadem University School of Medicine, Istanbul, Turkey
| | - Selçuk Peker
- Department of Neurosurgery, Koç University School of Medicine, Istanbul, Turkey
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3
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Bouter J, Reznik Y, Thariat J. Effects on the Hypothalamo-Pituitary Axis in Patients with CNS or Head and Neck Tumors following Radiotherapy. Cancers (Basel) 2023; 15:3820. [PMID: 37568636 PMCID: PMC10417001 DOI: 10.3390/cancers15153820] [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: 06/12/2023] [Revised: 07/23/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Knowledge about the precise effects of radiotherapy on hypothalamo-pituitary functions is limited. Reduction of side effects is a major goal of advanced radiotherapy modalities. We assessed strategies for monitoring and replacement of hormone deficiencies in irradiated patients. METHODS A search strategy was systematically conducted on PubMed®. Additional articles were retrieved to describe endocrine mechanisms. RESULTS 45 studies were evaluated from 2000 to 2022. They were predominantly retrospective and highly heterogeneous concerning patient numbers, tumor types, radiotherapy technique and follow-up. Endocrine deficiencies occurred in about 40% of patients within a median follow-up of 5.6 years without a clear difference between radiotherapy modalities. Somatotropic and thyrotropic axes were, respectively, the most and least radiosensitive. CONCLUSIONS Current pituitary gland dose constraints may underestimate radiation-induced endocrine deficiencies, thus impairing quality of life. Little difference might be expected between radiation techniques for PG tumors. For non-PG tumors, dose constraints should be applied more systematically.
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Affiliation(s)
- Jordan Bouter
- Radiotherapy Department, Centre François Baclesse, Avenue du Général Harris, 14000 Caen, France;
| | - Yves Reznik
- Department of Endocrinology, University Hospital of Caen, Avenue de la Côte de Nacre, 14033 Caen, France;
| | - Juliette Thariat
- Radiotherapy Department, Centre François Baclesse, Avenue du Général Harris, 14000 Caen, France;
- Corpuscular Physics Laboratory, ENSICAEN, Boulevard Maréchal Juin, 14050 Caen, France
- Unicaen—Normandie Université, 14050 Caen, France
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4
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Mantziaris G, Pikis S, Chytka T, Liščák R, Sheehan K, Sheehan D, Peker S, Samanci Y, Bindal SK, Niranjan A, Lunsford LD, Kaur R, Madan R, Tripathi M, Pangal DJ, Strickland BA, Zada G, Langlois AM, Mathieu D, Warnick RE, Patel S, Minier Z, Speckter H, Xu Z, Kormath Anand R, Sheehan JP. Adjuvant versus on-progression Gamma Knife radiosurgery for residual nonfunctioning pituitary adenomas: a matched-cohort analysis. J Neurosurg 2023; 138:1662-1668. [PMID: 36401547 DOI: 10.3171/2022.10.jns221873] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/07/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Radiological progression occurs in 50%-60% of residual nonfunctioning pituitary adenomas (NFPAs). Stereotactic radiosurgery (SRS) is a safe and effective management option for residual NFPAs, but there is no consensus on its optimal timing. This study aims to define the optimal timing of SRS for residual NFPAs. METHODS This retrospective, multicenter study involved 375 patients with residual NFPAs managed with SRS. The patients were divided into adjuvant (ADJ; treated for stable residual NFPA within 6 months of resection) and progression (PRG) cohorts (treated for residual NFPA progression). Factors associated with tumor progression and clinical deterioration were analyzed. RESULTS Following propensity-score matching, each cohort consisted of 130 patients. At last follow-up, tumor control was achieved in 93.1% of patients in the ADJ cohort and in 96.2% of patients in the PRG cohort (HR 1.6, 95% CI 0.55-4.9, p = 0.37). Hypopituitarism was associated with a maximum point dose of > 8 Gy to the pituitary stalk (HR 4.5, 95% CI 1.6-12.6, p = 0.004). No statistically significant difference was noted in crude new-onset hypopituitarism rates (risk difference [RD] = -0.8%, p > 0.99) or visual deficits (RD = -2.3%, p = 0.21) between the two cohorts at the last follow-up. The median time from resection to new hypopituitarism was longer in the PRG cohort (58.9 vs 29.7 months, p = 0.01). CONCLUSIONS SRS at residual NFPA progression does not appear to alter the probability of tumor control or hormonal/visual deficits compared with adjuvant SRS. Deferral of radiosurgical management to the time of radiological progression could significantly prolong the time to radiosurgically induced pituitary dysfunction. A lower maximum point dose (< 8 Gy) to the pituitary stalk portended a more favorable chance of preserving pituitary function after SRS.
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Affiliation(s)
- Georgios Mantziaris
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Stylianos Pikis
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Tomas Chytka
- 2Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liščák
- 2Department of Radiation and Stereotactic Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Kimball Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Darrah Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Selcuk Peker
- 3Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- 3Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Shray K Bindal
- 4Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Ajay Niranjan
- 4Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 4Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Rupinder Kaur
- 5Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Renu Madan
- 5Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manjul Tripathi
- 5Department of Neurosurgery and Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Dhiraj J Pangal
- 6Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California
| | - Ben A Strickland
- 6Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California
| | - Gabriel Zada
- 6Department of Neurosurgery, Keck School of Medicine of USC, Los Angeles, California
| | - Anne-Marie Langlois
- 7Division of Neurosurgery, Université de Sherbrooke, Centre de recherché du CHUS, Sherbrooke, Québec, Canada
| | - David Mathieu
- 7Division of Neurosurgery, Université de Sherbrooke, Centre de recherché du CHUS, Sherbrooke, Québec, Canada
| | - Ronald E Warnick
- 8Gamma Knife Center, Jewish Hospital, Mayfield Clinic, Cincinnati, Ohio
| | - Samir Patel
- 9Division of Radiation Oncology, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada; and
| | - Zayda Minier
- 10Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo, Dominican Republic
| | - Herwin Speckter
- 10Department of Radiology, Dominican Gamma Knife Center and CEDIMAT, Santo Domingo, Dominican Republic
| | - Zhiyuan Xu
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Rithika Kormath Anand
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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5
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Palmisciano P, Ogasawara C, Ogasawara M, Ferini G, Scalia G, Haider AS, Bin Alamer O, Salvati M, Umana GE. Endocrine disorders after primary gamma knife radiosurgery for pituitary adenomas: A systematic review and meta-analysis. Pituitary 2022; 25:404-419. [PMID: 35349010 DOI: 10.1007/s11102-022-01219-x] [Citation(s) in RCA: 8] [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] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Gamma Knife radiosurgery (GKRS) is feasible for pituitary adenomas, but post-surgery GKRS may cause severe hormone deficits. We reviewed the literature on primary GKRS for pituitary adenoma focusing on radiation-induced hormone deficiencies. METHODS PubMed, Web-of-Science, Scopus, and Cochrane were searched upon the PRISMA guidelines to include studies describing primary GKRS for pituitary adenomas. Pooled-rates of GKRS-induced hormone deficiencies and clinical-radiological responses were analyzed with a random-effect model meta-analysis. RESULTS We included 24 studies comprising 1381 patients. Prolactinomas were the most common (34.2%), and 289 patients had non-functioning adenomas (20.9%). Median tumor volume was 1.6cm3 (range, 0.01-31.3), with suprasellar extension and cavernous sinus invasion detected in 26% and 31.1% cases. GKRS was delivered with median marginal dose 22.6 Gy (range, 6-49), maximum dose 50 Gy (range, 25-90), and isodose line 50% (range, 9-100%). Median maximum point doses were 9 Gy (range, 0.5-25) to the pituitary stalk, 7 Gy (range, 1-38) to the optic apparatus, and 5 Gy (range, 0.4-12.3) to the optic chiasm. Pooled 5 year rates of endocrine normalization and local tumor control were 48% (95%CI 45-51%) and 97% (95%CI 95-98%). 158 patients (11.4%) experienced endocrinopathies at a median of 45 months (range, 4-187.3) after GKRS, with pooled 5-year rates of 8% (95%CI 6-9%). GKRS-induced hormone deficiencies comprised secondary hypothyroidism (42.4%) and hypogonadotropic hypogonadism (33.5%), with panhypopituitarism reported in 31 cases (19.6%). CONCLUSION Primary GKRS for pituitary adenoma may correlate with lower rates of radiation-induced hypopituitarism (11.4%) than post-surgery GKRS (18-32%). Minimal doses to normal pituitary structures and long-term endocrine follow-up are of primary importance.
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Affiliation(s)
- Paolo Palmisciano
- Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | | | | | - Gianluca Ferini
- Department of Radiation Oncology, REM Radioterapia srl, Viagrande, Italy
| | - Gianluca Scalia
- Department of Neurosurgery, Highly Specialized Hospital of National Importance "Garibaldi", Catania, Italy
| | - Ali S Haider
- Texas A&M University College of Medicine, Houston, TX, USA
| | - Othman Bin Alamer
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maurizio Salvati
- Department of Neurosurgery, IRCCS, Sapienza University of Rome, NeuromedPozzilli, Italy
| | - Giuseppe E Umana
- Department of Neurosurgery, Trauma Center, Gamma Knife Center, Cannizzaro Hospital, Via Messina 829, 95126, Catania, Italy.
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6
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Ganz JC. Pituitary adenomas. PROGRESS IN BRAIN RESEARCH 2022; 268:191-215. [PMID: 35074080 DOI: 10.1016/bs.pbr.2021.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pituitary adenomas produce a complex collection of disorders. Some are incidental findings. Some distort local anatomical structures which can lead to disorders of vision or hormone production. Some produce excesses of hormones which can be either life threatening or clinically distressing. The management requires the expertise of a variety of experts who plan together. No single treatment is universally successful in controlling these conditions. Medical, biochemical, surgical and radiosurgical management can all have parts to play. Coordinate co-operation between specialists will provide patients with the best available treatment.
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Affiliation(s)
- Jeremy C Ganz
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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7
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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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8
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Pomeraniec IJ, Xu Z, Lee CC, Yang HC, Chytka T, Liscak R, Martinez-Alvarez R, Martinez-Moreno N, Attuati L, Picozzi P, Kondziolka D, Mureb M, Bernstein K, Mathieu D, Maillet M, Ogino A, Long H, Kano H, Lunsford LD, Zacharia BE, Mau C, Tuanquin LC, Cifarelli C, Arsanious D, Hack J, Warnick RE, Strickland BA, Zada G, Chang EL, Speckter H, Patel S, Ding D, Sheehan D, Sheehan K, Kvint S, Buch LY, Haber AR, Shteinhart J, Vance ML, Sheehan JP. Dose to neuroanatomical structures surrounding pituitary adenomas and the effect of stereotactic radiosurgery on neuroendocrine function: an international multicenter study. J Neurosurg 2021; 136:813-821. [PMID: 34560630 DOI: 10.3171/2021.3.jns203812] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stereotactic radiosurgery (SRS) provides a safe and effective therapeutic modality for patients with pituitary adenomas. The mechanism of delayed endocrine deficits based on targeted radiation to the hypothalamic-pituitary axis remains unclear. Radiation to normal neuroendocrine structures likely plays a role in delayed hypopituitarism after SRS. In this multicenter study by the International Radiosurgery Research Foundation (IRRF), the authors aimed to evaluate radiation tolerance of structures surrounding pituitary adenomas and identify predictors of delayed hypopituitarism after SRS for these tumors. METHODS This is a retrospective review of patients with pituitary adenomas who underwent single-fraction SRS from 1997 to 2019 at 16 institutions within the IRRF. Dosimetric point measurements of 14 predefined neuroanatomical structures along the hypothalamus, pituitary stalk, and normal pituitary gland were made. Statistical analyses were performed to determine the impact of doses to critical structures on clinical, radiographic, and endocrine outcomes. RESULTS The study cohort comprised 521 pituitary adenomas treated with SRS. Tumor control was achieved in 93.9% of patients over a median follow-up period of 60.1 months, and 22.5% of patients developed new loss of pituitary function with a median treatment volume of 3.2 cm3. Median maximal radiosurgical doses to the hypothalamus, pituitary stalk, and normal pituitary gland were 1.4, 7.2, and 11.3 Gy, respectively. Nonfunctioning adenoma status, younger age, higher margin dose, and higher doses to the pituitary stalk and normal pituitary gland were independent predictors of new or worsening hypopituitarism. Neither the dose to the hypothalamus nor the ratio between doses to the pituitary stalk and gland were significant predictors. The threshold of the median dose to the pituitary stalk for new endocrinopathy was 10.7 Gy in a single fraction (OR 1.77, 95% CI 1.17-2.68, p = 0.006). CONCLUSIONS SRS for the treatment of pituitary adenomas affords a high tumor control rate with an acceptable risk of new or worsening endocrinopathy. This evaluation of point dosimetry to adjacent neuroanatomical structures revealed that doses to the pituitary stalk, with a threshold of 10.7 Gy, and doses to the normal gland significantly increased the risk of post-SRS hypopituitarism. In patients with preserved pre-SRS neuroendocrine function, limiting the dose to the pituitary stalk and gland while still delivering an optimal dose to the tumor appears prudent.
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Affiliation(s)
| | | | - Cheng-Chia Lee
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Huai-Che Yang
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Tomas Chytka
- 5Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Roman Liscak
- 5Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Luca Attuati
- 7Department of Neurosurgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Piero Picozzi
- 7Department of Neurosurgery, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | | | | | | | | | - Michel Maillet
- 11Endocrinology, Université de Sherbrooke, Centre de recherche du Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada
| | - Akiyoshi Ogino
- 12Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hao Long
- 12Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Hideyuki Kano
- 12Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- 12Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | - Leonard C Tuanquin
- 14Radiation Oncology, Penn State Health-Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Joshua Hack
- 16Radiation Oncology, West Virginia University Medical Center, Morgantown, West Virginia
| | - Ronald E Warnick
- 17Gamma Knife Center, Jewish Hospital, Mayfield Clinic, Cincinnati, Ohio
| | | | | | - Eric L Chang
- 19Radiation Oncology, University of Southern California Keck School of Medicine, Los Angeles, California
| | - Herwin Speckter
- 20Centro Gamma Knife Dominicano and Radiology Department, CEDIMAT, Santo Domingo, Dominican Republic
| | - Samir Patel
- 21Division of Radiation Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Dale Ding
- 22Department of Neurosurgery, University of Louisville Hospital, Louisville, Kentucky; and
| | | | | | - Svetlana Kvint
- 23Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Love Y Buch
- 23Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander R Haber
- 23Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacob Shteinhart
- 23Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Lee Vance
- Departments of1Neurosurgery.,2Radiation Oncology, and.,3Medicine and Endocrinology, University of Virginia Health Science Center, Charlottesville, Virginia
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9
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Liu X, Dai C, Feng M, Li M, Chen G, Wang R. Diagnosis and treatment of refractory pituitary adenomas: a narrative review. Gland Surg 2021; 10:1499-1507. [PMID: 33968701 DOI: 10.21037/gs-20-873] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although aggressive pituitary adenomas (PAs) have been proposed and widely discussed for more than a decade, there is no general agreement regarding their definition, diagnosis or management. As one of the largest pituitary centers in China, we have diagnosed and treated more than fifty cases of aggressive PA and 3 pituitary carcinomas in the past 5 years and proposed a new term, i.e., refractory PAs, to define these adenomas. The definitions of aggressive and refractory PAs overlap with each other, though there are some differences between them. We interpret the definition for refractory PA in this review, emphasizing that more attention and early identification of these adenomas are needed. Although temozolomide (TMZ) has been used to treat pituitary carcinomas and refractory PA since 2006, which has significantly improved the prognosis of these patients, treatment of refractory PA is a tremendous challenge for endocrinologists and neurosurgeons. Overall, refractory PA is defined as PA with a Ki-67 labeling index ≥3%, a faster growth rate than that of normal PA, infiltration of surrounding tissues, recurrence or regrowth in the early postoperative period, and continued growth and/or secretion of excessive hormones despite attempts to control it. These criteria for refractory PA are stricter than for aggressive PA. The diagnosis and treatment of refractory PA requires the collaboration of a multidisciplinary team to achieve the best results.
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Affiliation(s)
- Xiaohai Liu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Congxin Dai
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Tongren Hospital Capital Medical University, Beijing, China
| | - Ming Feng
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingchu Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Ge Chen
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, China.,Chinese Pituitary Specialists Congress, Beijing, China
| | - Renzhi Wang
- Chinese Pituitary Specialists Congress, Beijing, China.,Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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10
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Li Y, Wu L, Quan T, Fu J, Cao L, Li X, Liang S, Huang M, Deng Y, Yu J. Characteristic of Tumor Regrowth After Gamma Knife Radiosurgery and Outcomes of Repeat Gamma Knife Radiosurgery in Nonfunctioning Pituitary Adenomas. Front Oncol 2021; 11:627428. [PMID: 33763363 PMCID: PMC7982800 DOI: 10.3389/fonc.2021.627428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/21/2021] [Indexed: 11/16/2022] Open
Abstract
Objective This study aimed to report the characteristic of tumor regrowth after gamma knife radiosurgery (GKRS) and outcomes of repeat GKRS in nonfunctioning pituitary adenomas (NFPAs). Design and Methods This retrospective study consisted of 369 NFPA patients treated with GKRS. The median age was 45.2 (range, 7.2–84.0) years. The median tumor volume was 3.5 (range, 0.1–44.3) cm3. Results Twenty-four patients (6.5%) were confirmed as regrowth after GKRS. The regrowth-free survivals were 100%, 98%, 97%, 86% and 77% at 1, 3, 5, 10 and 15 year, respectively. In multivariate analysis, parasellar invasion and margin dose (<12 Gy) were associated with tumor regrowth (hazard ratio [HR] = 3.125, 95% confidence interval [CI] = 1.318–7.410, p = 0.010 and HR = 3.359, 95% CI = 1.347–8.379, p = 0.009, respectively). The median time of regrowth was 86.1 (range, 23.2–236.0) months. Previous surgery was associated with tumor regrowth out of field (p = 0.033). Twelve patients underwent repeat GKRS, including regrowth in (n = 8) and out of field (n = 4). Tumor shrunk in seven patients (58.3%), remained stable in one (8.3%) and regrowth in four (33.3%) with a median repeat GKRS margin dose of 12 (range, 10.0–14.0) Gy. The actuarial tumor control rates were 100%, 90%, 90%, 68%, and 68% at 1, 3, 5, 10, and 15 years after repeat GKRS, respectively. Conclusions Parasellar invasion and tumor margin dose (<12 Gy) were independent risk factors for tumor regrowth after GKRS. Repeat GKRS might be effective on tumor control for selected patients. For regrowth in field due to relatively insufficient radiation dose, repeat GKRS might offer satisfactory tumor control. For regrowth out of field, preventing regrowth out of field was the key management. Sufficient target coverage and close follow-up might be helpful.
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Affiliation(s)
- Yanli Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Lisha Wu
- Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Tingting Quan
- Department of Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Junyi Fu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Linhui Cao
- Department of Traditional Chinese Medicine, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xi Li
- Department of Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shunyao Liang
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Minyi Huang
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yinhui Deng
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jinxiu Yu
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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11
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Gamma Knife radiosurgery as the initial treatment for elderly patients with nonfunctioning pituitary adenomas. J Neurooncol 2021; 152:257-264. [PMID: 33638114 DOI: 10.1007/s11060-021-03724-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 12/22/2020] [Indexed: 02/05/2023]
Abstract
PURPOSE The aim of this study was to investigate the efficacy and safety of initial Gamma Knife radiosurgery (GKRS) for elderly patients with nonfunctioning pituitary adenomas (NFPAs). METHODS We retrospectively reviewed 45 elderly patients underwent GKRS as the initial treatment for NFPAs at our institution between December 2007 and December 2017. Patients' radiographic and clinical data were collected. RESULTS The median age of patients at the time of GKRS was 71 years (range 65-82 years). The median tumor volume was 2.6 cm3 (range 0.3-21.8 cm3). The median marginal dose was 13 Gy (range 6-23 Gy). The median maximum dose to the optic apparatus was 6.5 Gy (range 2.3-10.3 Gy). Thirty-five patients (77.8%) achieved tumor regression, 6 patients (13.3%) had tumor stable and 4 patients (8.9%) occurred tumor progression during a median radiological follow-up time of 51.4 months (range 11.1-158.7 months). The crude tumor control rate was 91.1%. The actuarial tumor control rates were 100%, 95.0%, 87.6%, and 87.6%, at 1, 3, 5, and 10 years after initial GKRS, respectively. New-onset hypopituitarism occurred in 6 patients. Two patients with pre-GKRS visual dysfunction developed further deterioration of visual function. No other radiation-induced complications were noted. CONCLUSION Initial GKRS can provide a high tumor control rate as well as low risk of postradiosurgical complications for elderly patients with NFPAs. Attention should be paid to avoid radiation-related adverse effects including hypopituitarism, optic neuropathy and cranial neuropathy in elderly patients.
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12
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Pérez-López C, Álvarez-Escolá C, Isla Guerrero A. Therapeutic approach to non-functioning pituitary adenomas. Med Clin (Barc) 2021; 156:284-289. [PMID: 33454125 DOI: 10.1016/j.medcli.2020.08.019] [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] [Received: 07/07/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 10/22/2022]
Abstract
The treatment of non-functioning pituitary adenomas raises two questions: when should they be treated and what role does each available treatment play. We review the usefulness of the different treatments and propose a therapeutic scheme based on the existing literature. Active treatment of pituitary adenomas should be performed when they produce symptoms, have contact with the optic tract, or have grown on imaging tests. The treatment is surgical, using radiotherapy for cases with significant non-removable postsurgical tumour remnants and for those in which histopathology studies show aggressive features. Medical treatment is reserved for situations in which surgical and radiotherapy treatments have been exhausted. The most advisable surgical treatment is endoscopic, although experienced neurosurgeons achieve results with microsurgery that are only slightly inferior.
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Affiliation(s)
- Carlos Pérez-López
- Servicio de Neurocirugía. Hospital Universitario La Paz, Madrid, España.
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13
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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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14
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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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15
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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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16
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Pomeraniec IJ, Taylor DG, Cohen-Inbar O, Xu Z, Lee Vance M, Sheehan JP. Radiation dose to neuroanatomical structures of pituitary adenomas and the effect of Gamma Knife radiosurgery on pituitary function. J Neurosurg 2020; 132:1499-1506. [PMID: 30978685 DOI: 10.3171/2019.1.jns182296] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/24/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) provides a safe and effective management option for patients with all types of pituitary adenomas. The long-term adverse effects of targeted radiation to the hypothalamic-pituitary axis in relationship to radiation dose remain unclear. In this retrospective review, the authors investigated the role of differential radiation doses in predicting long-term clinical outcomes and pituitary function after GKRS for pituitary adenomas. METHODS A cohort of 236 patients with pituitary tumors (41.5% nonfunctioning, 58.5% functioning adenomas) was treated with GKRS between 1998 and 2015. Point dosimetric measurements, with no minimum volume, to 14 consistent points along the hypothalamus bilaterally, pituitary stalk, and normal pituitary were made. Statistical analyses were performed to determine the impact of doses to critical structures on clinical, radiological, and endocrine outcomes. RESULTS With a median follow-up duration of 42.9 months, 18.6% of patients developed new loss of pituitary function. The median time to endocrinopathy was 21 months (range 2-157 months). The median dose was 2.1 Gy to the hypothalamus, 9.1 Gy to the pituitary stalk, and 15.3 Gy to the normal pituitary. Increasing age (p = 0.015, HR 0.98) and ratio of maximum dose to the pituitary stalk over the normal pituitary gland (p = 0.013, HR 0.22) were independent predictors of new or worsening hypopituitarism in the multivariate analysis. Sex, margin dose, treatment volume, nonfunctioning adenoma status, or ratio between doses to the pituitary stalk and hypothalamus were not significant predictors. CONCLUSIONS GKRS offers a low rate of delayed pituitary insufficiency for pituitary adenomas. Doses to the hypothalamus are low and generally do not portend endocrine deficits. Patients who are treated with a high dose to the pituitary stalk relative to the normal gland are at higher risk of post-GKRS endocrinopathy. Point dosimetry to specific neuroanatomical structures revealed that a ratio of stalk-to-gland radiation dose of 0.8 or more significantly increased the risk of endocrinopathy following GKRS. Improvement in the gradient index toward the stalk and normal gland may help preserve endocrine function.
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Affiliation(s)
| | | | - Or Cohen-Inbar
- Departments of1Neurosurgery
- 4Department of Neurosurgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Mary Lee Vance
- Departments of1Neurosurgery
- 3Medicine and Endocrinology, University of Virginia Health Science Center, Charlottesville, Virginia; and
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17
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Yu J, Li Y, Quan T, Li X, Peng C, Zeng J, Liang S, Huang M, He Y, Deng Y. Initial Gamma Knife radiosurgery for nonfunctioning pituitary adenomas: results from a 26-year experience. Endocrine 2020; 68:399-410. [PMID: 32162186 DOI: 10.1007/s12020-020-02260-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 03/03/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the long-term outcomes of initial Gamma Knife radiosurgery (GKRS) for patients with nonfunctioning pituitary adenomas (NFPAs). DESIGN AND METHODS This was a single-center retrospective study. Eighty-one patients with NFPAs undergoing initial GKRS were enrolled. The median age was 44.9 years (range, 7.2-75.5 years). The median tumor volume was 2.3 cm3 (range, 0.1-31.3 cm3), and the median tumor margin dose was 13.0 Gy (range, 8-22 Gy). RESULTS Tumor shrunk in 63 patients (77.8%), remained stable in 9 (11.1%), treatment failure in 9 (11.1%) during a median follow-up of 67.1 months (range, 11.5-263.9 months). The tumor control rates were 100%, 99%, 95%, and 84%, at 1, 3, 5, and 10 years, respectively. In multivariate analysis, tumor volume (≥4 cm3) and margin dose (<12 Gy) were associated with treatment failure (hazard ratio (HR) = 7.093, 95% confidence interval (CI) = 1.098-45.083, p = 0.040, and HR = 9.643, 95% CI = 1.108-83.927, p = 0.040, respectively). New apoplexy occurred in seven patients (8.6%) after GKRS with a median time of 39.9 months (range, 11.9-166.8 months). In multivariate analysis, tumor volume (≥10 cm3) was a significant risk factor (HR = 10.642, 95% CI = 2.121-53.398, p = 0.004). New hypopituitarism occurred in 14 patients (17.3%). No factors were associated with new hypopituitarism. Four patients (4.9%) developed new or worsening visual dysfunction. No new cranial neuropathy was noted. CONCLUSIONS In this study, initial GKRS can provide a high tumor control rate, as well as a low incidence rate of complications in NFPAs. GKRS may be an alternative initial treatment for selected NFPAs.
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Affiliation(s)
- Jinxiu Yu
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, Guangdong, China.
| | - Yanli Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, Guangdong, China
| | - Tingting Quan
- Department of Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, China
| | - Xi Li
- Department of Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, Guangdong, China
| | - Chao Peng
- Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, Guangdong, China
| | - Jiamin Zeng
- Department of Pathology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, Guangdong, China
| | - Shunyao Liang
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, Guangdong, China
| | - Minyi Huang
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, Guangdong, China
| | - Yong He
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, Guangdong, China
| | - Yinhui Deng
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510260, Guangdong, China.
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18
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Yamamoto M, Aiyama H, Koiso T, Watanabe S, Kawabe T, Sato Y, Higuchi Y, Barfod BE, Kasuya H. Postsurgical Salvage Radiosurgery for Nonfunctioning Pituitary Adenomas Touching/Compressing the Optic Chiasm: Median 13-Year Postirradiation Imaging Follow-up Results. Neurosurgery 2020; 85:476-485. [PMID: 30169702 DOI: 10.1093/neuros/nyy357] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/11/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is little information on long-term outcomes after salvage treatment by either surgery or stereotactic radiosurgery (SRS) for patients with recurrent/residual nonfunctioning pituitary adenomas (NFPAs). OBJECTIVE To reappraise the efficacy and safety of SRS for patients with NFPAs touching/compressing the optic apparatus (OA). METHODS We studied 27 patients (14 females, 13 males; mean age: 61 [range, 19-85] yr) who underwent SRS between 1998 and 2008 for NFPAs with such condition. The median tumor volume was 4.9 (range, 1.8-50.8) cc. To avoid excess irradiation to the OA, the lower part of the tumor was covered with a 50% or a 60% isodose gradient, ie 49% to 98% (mean, 84%; median, 88%) of the entire tumor received the selected doses. Median doses at the tumor periphery/OA were 7.6/11.0 (interquartile range [IQR], 5.8-9.1/10.1-11.8) Gy. RESULTS Seven patients (26%) were confirmed to be deceased due to unrelated diseases at a median post-SRS period of 149 (IQR, 83-158) mo. Follow-up magnetic resonance imaging (MRI) showed tumor growth in 2 patients (7%) at the 11th and 134th post-SRS month; the former underwent surgery and the other SRS. Excluding these 2 patients, the latest follow-up MRI examinations, performed 13 to 238 (median: 168, IQR: 120-180) mo after SRS, showed no size changes in 5 (19%) and shrinkage in 20 (74%) patients. Cumulative incidences of tumor growth control were 96.3% and 91.8% at the 120th and 180th post-SRS month. None of our patients developed subjective symptoms suggesting SRS-induced optic neuropathy or endocrinological impairment. CONCLUSION In patients with NFPAs touching/compressing the OA, SRS achieves good long-term results.
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Affiliation(s)
- Masaaki Yamamoto
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan.,Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Hitoshi Aiyama
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan.,Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takao Koiso
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan.,Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Shinya Watanabe
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan.,Tsukuba Clinical Research and Development Organization, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Takuya Kawabe
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan.,Department of Neurosurgery, Rakusai Shimizu Hospital, Kyoto, Japan
| | - Yasunori Sato
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Bierta E Barfod
- Katsuta Hospital Mito GammaHouse, Hitachi-naka, Ibaraki, Japan
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
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19
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Kotecha R, Sahgal A, Rubens M, De Salles A, Fariselli L, Pollock BE, Levivier M, Ma L, Paddick I, Regis J, Sheehan J, Yomo S, Suh JH. Stereotactic radiosurgery for non-functioning pituitary adenomas: meta-analysis and International Stereotactic Radiosurgery Society practice opinion. Neuro Oncol 2020; 22:318-332. [PMID: 31790121 PMCID: PMC7058447 DOI: 10.1093/neuonc/noz225] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND This systematic review reports on outcomes and toxicities following stereotactic radiosurgery (SRS) for non-functioning pituitary adenomas (NFAs) and presents consensus opinions regarding appropriate patient management. METHODS Using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a systematic review was performed from articles of ≥10 patients with NFAs published prior to May 2018 from the Medline database using the key words "radiosurgery" and "pituitary" and/or "adenoma." Weighted random effects models were used to calculate pooled outcome estimates. RESULTS Of the 678 abstracts reviewed, 35 full-text articles were included describing the outcomes of 2671 patients treated between 1971 and 2017 with either single fraction SRS or hypofractionated stereotactic radiotherapy (HSRT). All studies were retrospective (level IV evidence). SRS was used in 27 studies (median dose: 15 Gy, range: 5-35 Gy) and HSRT in 8 studies (median total dose: 21 Gy, range: 12-25 Gy, delivered in 3-5 fractions). The 5-year random effects local control estimate after SRS was 94% (95% CI: 93.0-96.0%) and 97.0% (95% CI: 93.0-98.0%) after HSRT. The 10-year local control random effects estimate after SRS was 83.0% (95% CI: 77.0-88.0%). Post-SRS hypopituitarism was the most common treatment-related toxicity observed, with a random effects estimate of 21.0% (95% CI: 15.0-27.0%), whereas visual dysfunction or other cranial nerve injuries were uncommon (range: 0-7%). CONCLUSIONS SRS is an effective and safe treatment for patients with NFAs. Encouraging short-term data support HSRT for select patients, and mature outcomes are needed before definitive recommendations can be made. Clinical practice opinions were developed on behalf of the International Stereotactic Radiosurgery Society (ISRS).
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Affiliation(s)
- Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
| | - Muni Rubens
- Miami Cancer Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Antonio De Salles
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Laura Fariselli
- Radiotherapy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Bruce E Pollock
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Marc Levivier
- Department of Neurosurgery and Gamma Knife Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Ian Paddick
- Medical Physics Ltd, Reading, Cromwell Hospital, London, UK
| | - Jean Regis
- Functional and Stereotaxic Neurosurgery Department, Clinical Neuroscience Federation, Timone Hospital, Aix-Marseille University, Marseille, France
| | - Jason Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, 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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20
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Deng Y, Li Y, Li X, Wu L, Quan T, Peng C, Fu J, Yang X, Yu J. Long-term results of Gamma Knife Radiosurgery for Postsurgical residual or recurrent nonfunctioning Pituitary Adenomas. Int J Med Sci 2020; 17:1532-1540. [PMID: 32669956 PMCID: PMC7359386 DOI: 10.7150/ijms.47168] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/21/2020] [Indexed: 01/09/2023] Open
Abstract
Introduction: The aim of this retrospective study was to analyze the long-term outcomes and factors associated with treatment failure of Gamma Knife radiosurgery (GKRS) for postsurgical residual or recurrent nonfunctioning pituitary adenomas (NFPAs). Design and Methods: A total of 148 cases of postsurgical residual or recurrent NFPA patients were enrolled in the study. There were 111 cases with residual tumor and 37 cases with recurrent tumor. The median age was 46.0 years (Range: 10.9-75.8 years). The median tumor volume at GKRS was 3.6 cm3 (Range: 0.3-74.5 cm3), and the median tumor margin dose was 14.0 Gy (Range: 9 - 20 Gy). Results: Tumor shrunk in 111 patients (75%), remained stable in 17 patients (11.5%), and progressed in 20 patients (13.5%) during a median of 64.5 months (Range: 14.5 - 236.0 months) of imaging follow-up. The progression-free survival rates were 99%, 91%, 88% and 74% at 1, 3, 5 and 10 years after GKRS, respectively. In a multivariate analysis, tumor margin dose (<13 Gy) was significantly associated with tumor progression (hazard ratio=3.526, 95% confidence interval=1.400-8.877, p=0.007). New hypopituitarism occurred in 22 out of 80 patients (27.5%), including hypogonadism (n=7), hypothyroidism (n=9), hypocortisolism (n=15) and growth hormone deficiency (n=1). In univariate and multivariate analysis, there were no factors significantly associated with new hypopituitarism. Six patients (4.1%) developed new or worsening visual dysfunction. Four patients (2.7%) developed new cranial neuropathy. Conclusion: In this study, GKRS can offer a high tumor control rate as well as a low rate of complications in postsurgical residual or recurrent NFPA patients.
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Affiliation(s)
- Yinhui Deng
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Yanli Li
- Department of Endocrinology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Xi Li
- Department of Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Lisha Wu
- Department of Medical Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China. 510120
| | - Tingting Quan
- Department of Radiology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, Guangdong, China, 510060
| | - Chao Peng
- Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China. 510080
| | - Junyi Fu
- Department of Neurology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Xin Yang
- Department of Thoracic Surgery, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
| | - Jinxiu Yu
- Department of Radiotherapy, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China. 510260
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21
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Albano L, Losa M, Nadin F, Barzaghi LR, Parisi V, Del Vecchio A, Bolognesi A, Mortini P. Safety and efficacy of multisession gamma knife radiosurgery for residual or recurrent pituitary adenomas. Endocrine 2019; 64:639-647. [PMID: 30798432 DOI: 10.1007/s12020-019-01876-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/16/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To define the efficacy and complications of multisession Gamma Knife radiosurgery (MGKRS) delivered in three consecutive sessions for the treatment of residual or recurrent pituitary adenomas (PAs). METHODS This was a retrospective study of data from the Neurosurgery and Gamma Knife Radiosurgery Department at San Raffaele Hospital between May 2008 and September 2017. We recruited 47 consecutive patients undergoing MGKRS in three consecutive fractions for residual or recurrent PA with a distance from the anterior optic pathway inferior to 2-3 mm. RESULTS Thirty-eight (80.8%) patients had a nonfunctioning-PA (NFPA) while 9 (19.2%) had a hormone-secreting PA (HSPA). Tumor control was achieved in 100% of patients. Tumor shrinkage was seen in 33 out of 44 (75.0%) patients with a radiological follow-up. Mean tumor volume before MGKRS was 3.93 cm3. The mean tumor volume at last follow-up was 2.11 cm3, with a mean tumor shrinkage of 50.2%, as compared with baseline. One case of suspected radiation-induced optic neuropathy (RION) was documented while new-onset hypopituitarism for any axis occurred in 12 of the 31 (38.7%) patients at risk. The mean follow-up was 44.6 ± 4.0 months (range, 6-111 months). CONCLUSIONS MGKRS is a valid alternative to external fractionated radiotherapy and other types of stereotactic radiosurgery for the treatment of PAs, achieving a high tumor control rate with a low risk of visual deterioration. Moreover, the majority of patients showed a significant reduction of tumor size in the long term.
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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.
| | - Marco Losa
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Francesco Nadin
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lina Raffaella Barzaghi
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Veronica Parisi
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Antonella Del Vecchio
- Department of Medical Physics, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Angelo Bolognesi
- Department of Radiation therapy, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery and Gamma Knife Radiosurgery, I.R.C.C.S. San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
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22
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Castinetti F, Brue T, Ragnarsson O. Radiotherapy as a tool for the treatment of Cushing's disease. Eur J Endocrinol 2019; 180:D9-D18. [PMID: 30970325 DOI: 10.1530/eje-19-0092] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 04/03/2019] [Indexed: 11/08/2022]
Abstract
Treatment of Cushing's disease (CD) is one of the most challenging tasks in endocrinology. The first-line treatment, transsphenoidal pituitary surgery, is associated with a high failure rate and a high prevalence of recurrence. Re-operation is associated with an even higher rate of a failure and recurrence. There are three main second-line treatments for CD - pituitary radiation therapy (RT), bilateral adrenalectomy and chronic cortisol-lowering medical treatment. All these treatments have their limitations. While bilateral adrenalectomy provides permanent cure of the hypercortisolism in all patients, the unavoidable chronic adrenal insufficiency and the risk of development of Nelson syndrome are of concern. Chronic cortisol-lowering medical treatment is not efficient in all patients and side effects are often a limiting factor. RT is efficient for approximately two-thirds of all patients with CD. However, the high prevalence of pituitary insufficiency is of concern as well as potential optic nerve damage, development of cerebrovascular disease and secondary brain tumours. Thus, when it comes to decide appropriate treatment for patients with CD, who have either failed to achieve remission with pituitary surgery, or patients with recurrence, the pros and cons of all second-line treatment options must be considered.
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Affiliation(s)
- Frederic Castinetti
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Marseille Medical Genetics, Marseille, France
- Department of Endocrinology, Assistance Publique-Hôpitaux de Marseille, Hôpital de la Conception, Centre de Référence des Maladies Rares de l'hypophyse, Marseille, France
| | - Thierry Brue
- Aix-Marseille Université, Institut National de la Santé et de la Recherche Médicale, Marseille Medical Genetics, Marseille, France
- Department of Endocrinology, Assistance Publique-Hôpitaux de Marseille, Hôpital de la Conception, Centre de Référence des Maladies Rares de l'hypophyse, Marseille, France
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
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23
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Lee CC, Yang HC, Chen CJ, Lin CJ, Wu HM, Chung WY, Shiau CY, Guo WY, Pan DHC. Empirical versus progression-guided stereotactic radiosurgery for non-functional pituitary macroadenomas after subtotal resection. J Neurooncol 2019; 142:291-297. [PMID: 30635763 DOI: 10.1007/s11060-019-03095-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/08/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE There is a lack of consensus regarding whether if residual non-functional macroadenomas (NFM) should undergo empirical stereotactic radiosurgery (SRS) or be monitored until tumor progression before SRS treatment. The aim of this study is to compare the risks and benefits of empirical versus progression-guided SRS for NFM after subtotal resection. METHODS This is a retrospective study of consecutive NFM patients who subtotal surgical resection followed by SRS between 1999 and 2014. Patients were dichotomized into two groups: empirical SRS (SRS without evidence of tumor progression) and progression-guided SRS (SRS after demonstration of tumor progression) groups. Tumor response was categorized into: (1) regression, ≥ 10% decrease in tumor volume; (2) stable, < 10% increase or decrease in tumor volume; and (3) progression, ≥ 10% increase in tumor volume. Tumor control comprised stable tumor response and tumor regression. RESULTS Of the 112 patients who underwent SRS for NFM, 106 patients were treated for residual NFM after surgical resection, and included in the final analysis. The empirical SRS and progression-guided SRS groups comprised 46 and 60 patients, respectively. Overall tumor control rate was 88.7%. Higher rate of tumor control was achieved in the empirical SRS group compared to the progression-guided SRS group (95.65% vs. 83.33%, p = 0.047). Rates of new visual field deficit, cranial neuropathy and endocrinopathy were comparable between the two groups. Empirical SRS group had higher rates of progression-free survival compared to progression-guided SRS group (p = 0.015). Actuarial progression-free survival rates for the empirical SRS group were 93.2%, 93.2%, and 81.5% at 3, 5, and 10 years after SRS. Actuarial progression-free survival rates for the progression-guided SRS were 86.4%, 82.1%, and 68.4% at 3, 5, and 10 years after SRS. CONCLUSION Empirical SRS offers higher rates of tumor control and progression-free survival compared to progression-guided SRS in patients with residual NFM after surgical resection. Rates of new hypopituitarism and cranial neuropathies were comparable between the two groups.
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Affiliation(s)
- Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Chung-Jung Lin
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Hsiu-Mei Wu
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Wen-Yuh Chung
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Cheng-Ying Shiau
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,Cancer Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wan-Yuo Guo
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - David Hung-Chi Pan
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.,Department of Neurosurgery, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan, ROC
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24
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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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25
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Abstract
External beam radiotherapy (RT) is an essential part of the management of intracranial tumors and has been used in treating pituitary adenomas for more than five decades. It has been demonstrated that conventional RT for postoperative residual or progressive nonfunctioning pituitary adenomas (NFAs) present an excellent long-term local tumor control, although its use has been limited because of the potential late toxicity related to radiation treatments. Recent advances in radiation techniques have led to more accurate treatments, rendering obsolete many commonly held views of the "old" radiotherapy. New techniques include intensity modulated radiotherapy, volumetric-modulated arc therapy, and stereotactic techniques, either stereotactic radiosurgery or fractionated stereotactic radiotherapy. New techniques allow the delivering of higher radiation doses to the target with rapid dose fall-off in the surrounding normal tissues, and potentially limiting the long term toxicity of radiation. In this review, we present a critical analysis of the most recent available literature on the use of radiation in patients with NFAs, focusing particularly on the efficacy and safety of radiation stereotactic techniques.
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Affiliation(s)
- Giuseppe Minniti
- UPMC San Pietro FBF, Rome, Italy.
- IRCCS Neuromed, 86077, Pozzilli, IS, Italy.
| | - John Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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26
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Radiation Therapy in Tumors of the Pituitary Gland. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_6-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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27
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Raverot G, Burman P, McCormack A, Heaney A, Petersenn S, Popovic V, Trouillas J, Dekkers OM. European Society of Endocrinology Clinical Practice Guidelines for the management of aggressive pituitary tumours and carcinomas. Eur J Endocrinol 2018; 178:G1-G24. [PMID: 29046323 DOI: 10.1530/eje-17-0796] [Citation(s) in RCA: 332] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/12/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pituitary tumours are common and easily treated by surgery or medical treatment in most cases. However, a small subset of pituitary tumours does not respond to standard medical treatment and presents with multiple local recurrences (aggressive pituitary tumours) and in rare occasion with metastases (pituitary carcinoma). The present European Society of Endocrinology (ESE) guideline aims to provide clinical guidance on diagnosis, treatment and follow-up in aggressive pituitary tumours and carcinomas. METHODS We decided upfront, while acknowledging that literature on aggressive pituitary tumours and carcinomas is scarce, to systematically review the literature according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. The review focused primarily on first- and second-line treatment in aggressive pituitary tumours and carcinomas. We included 14 single-arm cohort studies (total number of patients = 116) most on temozolomide treatment (n = 11 studies, total number of patients = 106). A positive treatment effect was seen in 47% (95% CI: 36-58%) of temozolomide treated. Data from the recently performed ESE survey on aggressive pituitary tumours and carcinomas (165 patients) were also used as backbone for the guideline. SELECTED RECOMMENDATION: (i) Patients with aggressive pituitary tumours should be managed by a multidisciplinary expert team. (ii) Histopathological analyses including pituitary hormones and proliferative markers are needed for correct tumour classification. (iii) Temozolomide monotherapy is the first-line chemotherapy for aggressive pituitary tumours and pituitary carcinomas after failure of standard therapies; treatment evaluation after 3 cycles allows identification of responder and non-responder patients. (iv) In patients responding to first-line temozolomide, we suggest continuing treatment for at least 6 months in total. Furthermore, the guideline offers recommendations for patients who recurred after temozolomide treatment, for those who did not respond to temozolomide and for patients with systemic metastasis.
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Affiliation(s)
- Gerald Raverot
- Fédération d'Endocrinologie, Centre de Référence des Maladies Rares Hypophysaires HYPO, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
- Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
- INSERM U1052, CNRS UMR5286, Cancer Research Centre of Lyon, Lyon, France
| | - Pia Burman
- Department of Endocrinology, Skane University Hospital Malmö, University of Lund, Lund, Sweden
| | - Ann McCormack
- Garvan Institute, Sydney, Australia
- Department of Endocrinology, St Vincent's Hospital, University of New South Wales, Sydney, Australia
| | - Anthony Heaney
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Vera Popovic
- Medical Faculty, University Belgrade, Belgrade, Serbia
| | - Jacqueline Trouillas
- Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
- Centre de Pathologie et de Biologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Olaf M Dekkers
- Departments of Internal Medicine (Section Endocrinology) & Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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28
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Barber SM, Teh BS, Baskin DS. Fractionated Stereotactic Radiotherapy for Pituitary Adenomas: Single-Center Experience in 75 Consecutive Patients. Neurosurgery 2017; 79:406-17. [PMID: 26657072 DOI: 10.1227/neu.0000000000001155] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Early results of postoperative fractionated stereotactic radiotherapy (FSRT) for functional and nonfunctional pituitary adenomas appear promising, but the majority of available evidence draws from small series with insufficient follow-up data to draw meaningful conclusions. OBJECTIVE To evaluate the long-term outcomes of a large series of patients undergoing FSRT for both functional and nonfunctional pituitary adenomas with the Novalis system (BrainLAB, Heimstetten, Germany). METHODS Chart data for 75 consecutive patients undergoing FSRT for a pituitary tumor (21 functional and 54 nonfunctional adenomas) at our institution between January 2004 and June 2013 were reviewed. RESULTS Radiographic progression-free survival was 100% over a mean of 47.8 months of radiographic follow-up (range, 12.0-131.2 months). Hormonal normalization was seen in 69.2% of patients with functional adenomas after FSRT, whereas 30.8% experienced partial hormonal control. Mild, grade I acute adverse effects were observed during radiotherapy treatment in 36 patients (48%), and objective, persistent worsening of vision occurred in a single patient (1.5%) after FSRT. New hormonal deficits were seen in 28.0% of patients after FSRT. Radiographic responses were inversely related to tumor volume. CONCLUSION FSRT delivers radiographic and functional outcomes similar to those seen with stereotactic radiosurgery and conventional radiotherapy with less resultant toxicity. FSRT is most beneficial for smaller tumors (those <3 cm in diameter). ABBREVIATIONS EBRT, external beam radiotherapyFSRT, fractionated stereotactic radiotherapyOR, odds ratioPTV, planning target volumeSRS, stereotactic radiosurgery.
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Affiliation(s)
- Sean M Barber
- *Houston Methodist Neurological Institute, Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas; ‡Department of Radiation Oncology, Houston Methodist Hospital, Houston, Texas; §Kenneth R. Peak Brain and Pituitary Tumor Treatment Center, Houston Methodist Hospital, Houston, Texas
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29
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Mehta GU, Ding D, Patibandla MR, Kano H, Sisterson N, Su YH, Krsek M, Nabeel AM, El-Shehaby A, Kareem KA, Martinez-Moreno N, Mathieu D, McShane B, Blas K, Kondziolka D, Grills I, Lee JY, Martinez-Alvarez R, Reda WA, Liscak R, Lee CC, Lunsford LD, Vance ML, Sheehan JP. Stereotactic Radiosurgery for Cushing Disease: Results of an International, Multicenter Study. J Clin Endocrinol Metab 2017; 102:4284-4291. [PMID: 28938462 DOI: 10.1210/jc.2017-01385] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 08/24/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Cushing disease (CD) due to adrenocorticotropic hormone-secreting pituitary tumors can be a management challenge. OBJECTIVE To better understand the outcomes of stereotactic radiosurgery (SRS) for CD and define its role in management. DESIGN International, multicenter, retrospective cohort analysis. SETTING Ten medical centers participating in the International Gamma Knife Research Foundation. PATIENTS Patients with CD with >6 months endocrine follow-up. INTERVENTION SRS using Gamma Knife radiosurgery. MAIN OUTCOME MEASURES The primary outcome was control of hypercortisolism (defined as normalization of free urinary cortisol). Radiologic response and adverse radiation effects (AREs) were recorded. RESULTS In total, 278 patients met inclusion criteria, with a mean follow-up of 5.6 years (0.5 to 20.5 years). Twenty-two patients received SRS as a primary treatment of CD. Mean margin dose was 23.7 Gy. Cumulative initial control of hypercortisolism was 80% at 10 years. Mean time to cortisol normalization was 14.5 months. Recurrences occurred in 18% with initial cortisol normalization. Overall, the rate of durable control of hypercortisolism was 64% at 10 years and 68% among patients who received SRS as a primary treatment. AREs included hypopituitarism (25%) and cranial neuropathy (3%). Visual deficits were related to treatment of tumor within the suprasellar cistern (P = 0.01), whereas both visual (P < 0.0001) and nonvisual cranial neuropathy (P = 0.02) were related to prior pituitary irradiation. CONCLUSIONS SRS for CD is well tolerated and frequently results in control of hypercortisolism. However, recurrences can occur. SRS should be considered for patients with persistent hypercortisolism after pituitary surgery and as a primary treatment in those unfit for surgery. Long-term endocrine follow-up is essential after SRS.
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Affiliation(s)
- Gautam U Mehta
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Dale Ding
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Mohana Rao Patibandla
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Hideyuki Kano
- Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Nathaniel Sisterson
- Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Yan-Hua Su
- Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei 11217, Taiwan, Republic of China
| | - Michal Krsek
- Second Department of Medicine, Third Faculty of Medicine of the Charles University, Faculty Hospital Kralovske Vinohrady, 11636 Prague, Czech Republic
| | - Ahmed M Nabeel
- Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Benha University, Benha, Egypt 11566
| | - Amr El-Shehaby
- Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt 11566
| | - Khaled A Kareem
- Clinical Oncology Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt 11566
| | - Nuria Martinez-Moreno
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, 28034 Madrid, Spain
| | - David Mathieu
- Division of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Québec J1H 5N4, Canada
| | - Brendan McShane
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Kevin Blas
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan 48073
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Lagone, Medical Center, New York, New York 10016
| | - Inga Grills
- Department of Radiation Oncology, Beaumont Health System, Royal Oak, Michigan 48073
| | - John Y Lee
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania 19104
| | - Roberto Martinez-Alvarez
- Department of Functional Neurosurgery and Radiosurgery, Ruber International Hospital, 28034 Madrid, Spain
| | - Wael A Reda
- Neurosurgery Department, Gamma Knife Center Cairo-Nasser Institute, Ain Shams University, Cairo, Egypt 11566
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, 11636 Prague, Czech Republic
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurologic Institute, Taipei Veterans General Hospital, Taipei 11217, Taiwan, Republic of China
| | - L Dade Lunsford
- Department of Neurologic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213
| | - Mary Lee Vance
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
- Department of Medicine, University of Virginia Health System, Charlottesville, Virginia 22908
| | - Jason P Sheehan
- Department of Neurologic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908
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Pomeraniec IJ, Kano H, Xu Z, Nguyen B, Siddiqui ZA, Silva D, Sharma M, Radwan H, Cohen JA, Dallapiazza RF, Iorio-Morin C, Wolf A, Jane JA, Grills IS, Mathieu D, Kondziolka D, Lee CC, Wu CC, Cifarelli CP, Chytka T, Barnett GH, Lunsford LD, Sheehan JP. Early versus late Gamma Knife radiosurgery following transsphenoidal surgery for nonfunctioning pituitary macroadenomas: a multicenter matched-cohort study. J Neurosurg 2017; 129:648-657. [PMID: 29076785 DOI: 10.3171/2017.5.jns163069] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Gamma Knife radiosurgery (GKRS) is frequently used to treat residual or recurrent nonfunctioning pituitary macroadenomas. There is no consensus as to whether GKRS should be used early after surgery or if radiosurgery should be withheld until there is evidence of imaging-defined progression of tumor. Given the high incidence of adenoma progression after subtotal resection over time, the present study intended to evaluate the effect of timing of radiosurgery on outcome. METHODS This is a multicenter retrospective review of patients with nonfunctioning pituitary macroadenomas who underwent transsphenoidal surgery followed by GKRS from 1987 to 2015 at 9 institutions affiliated with the International Gamma Knife Research Foundation. Patients were matched by adenoma and radiosurgical parameters and stratified based on the interval between last resection and radiosurgery. Operative results, imaging data, and clinical outcomes were compared across groups following early (≤ 6 months after resection) or late (> 6 months after resection) radiosurgery. RESULTS After matching, 222 patients met the authors' study criteria (from an initial collection of 496 patients) and were grouped based on early (n = 111) or late (n = 111) GKRS following transsphenoidal surgery. There was a greater risk of tumor progression after GKRS (p = 0.013) and residual tumor (p = 0.038) in the late radiosurgical group over a median imaging follow-up period of 68.5 months. No significant difference in the occurrence of post-GKRS endocrinopathy was observed (p = 0.68). Thirty percent of patients without endocrinopathy in the early cohort developed new endocrinopathies during the follow-up period versus 27% in the late cohort (p = 0.84). Fourteen percent of the patients in the early group and 25% of the patients in the late group experienced the resolution of endocrine dysfunction after original presentation (p = 0.32). CONCLUSIONS In this study, early GKRS was associated with a lower risk of radiological progression of subtotally resected nonfunctioning pituitary macroadenomas compared with expectant management followed by late radiosurgery. Delaying radiosurgery may increase patient risk for long-term adenoma progression. The timing of radiosurgery does not appear to significantly affect the rate of delayed endocrinopathy.
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Affiliation(s)
- I Jonathan Pomeraniec
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Hideyuki Kano
- 8Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Zhiyuan Xu
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Brandon Nguyen
- 2Department of Radiation Oncology, William Beaumont Hospital-Royal Oak, Michigan
| | - Zaid A Siddiqui
- 2Department of Radiation Oncology, William Beaumont Hospital-Royal Oak, Michigan
| | - Danilo Silva
- 3Cleveland Clinic Foundation, Center for Neurological Restoration, Cleveland, Ohio
| | - Mayur Sharma
- 3Cleveland Clinic Foundation, Center for Neurological Restoration, Cleveland, Ohio
| | - Hesham Radwan
- 3Cleveland Clinic Foundation, Center for Neurological Restoration, Cleveland, Ohio
| | - Jonathan A Cohen
- 8Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Robert F Dallapiazza
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christian Iorio-Morin
- 6Department of Neurosurgery, Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada
| | - Amparo Wolf
- 4Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - John A Jane
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Inga S Grills
- 2Department of Radiation Oncology, William Beaumont Hospital-Royal Oak, Michigan
| | - David Mathieu
- 6Department of Neurosurgery, Centre Hospitalier Universitaire de Sherbrooke, Quebec, Canada
| | - Douglas Kondziolka
- 4Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Cheng-Chia Lee
- 7Department of Neurosurgery, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Chih-Chun Wu
- 7Department of Neurosurgery, Taipei Veterans General Hospital, Taipei City, Taiwan
| | - Christopher P Cifarelli
- 9Department of Neurosurgery, West Virginia University Medical Center, Morgantown, West Virginia
| | - Tomas Chytka
- 5Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Gene H Barnett
- 3Cleveland Clinic Foundation, Center for Neurological Restoration, Cleveland, Ohio
| | - L Dade Lunsford
- 8Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Jason P Sheehan
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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Prognostic significance of corticotroph staining in radiosurgery for non-functioning pituitary adenomas: a multicenter study. J Neurooncol 2017; 135:67-74. [PMID: 28913674 DOI: 10.1007/s11060-017-2520-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2017] [Accepted: 05/29/2017] [Indexed: 10/18/2022]
Abstract
Silent corticotroph staining pituitary adenoma (SCA) represents an uncommon subset of Non-Functioning adenomas (NFAs), hypothesized to be more locally aggressive. In this retrospective multicenter study, we investigate the safety and effectiveness of Stereotactic Radiosurgery (SRS) in patients with SCA compared with other non-SCA NFA's. Eight centers participating in the International Gamma-Knife Research Foundation (IGKRF) contributed to this study. Outcomes of 50 patients with confirmed SCAs and 307 patients with confirmed non-SCA NFA's treated with SRS were evaluated. Groups were matched. SCA was characterized by a lack of clinical evidence of Cushing disease, yet with positive immunostaining for corticotroph. Median age was 55.2 years (13.7-87). All patients underwent at least one trans-sphenoidal tumor resection prior to SRS. SRS parameters were comparable as well. Median follow-up 40 months (6-163). Overall tumor control rate (TCR) 91.2% (n = 280). In the SCA group, TCR were 82% (n = 41) versus 94.1% (n = 289) for the control-NFA (p = 0.0065). The SCA group showed a significantly higher incidence of new post-SRS visual deficit (p < 0.0001) assigned to tumor progression and growth, and post-SRS weakness and fatigue (p < 0.0001). In univariate and multivariate analysis, only the status of silent corticotroph staining (p = 0.005, p = 0.009 respectively) and margin dose (p < 0.0005, p = 0.0037 respectively) significantly influenced progression rate. A margin dose of ≥17 Gy was noted to influence the adenoma progression rate in the entire cohort (p = 0.003). Silent corticotroph staining represents an independent factor for adenoma progression and hypopituitarism after SRS. A higher margin dose may convey a greater chance of TCR.
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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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Przybylowski CJ, Dallapiazza RF, Williams BJ, Pomeraniec IJ, Xu Z, Payne SC, Laws ER, Jane JA. Primary versus revision transsphenoidal resection for nonfunctioning pituitary macroadenomas: matched cohort study. J Neurosurg 2017; 126:889-896. [DOI: 10.3171/2016.3.jns152735] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The object of this study was to compare the outcomes of primary and revision transsphenoidal resection (TSR) of nonfunctioning pituitary macroadenomas (NFPMAs) using endoscopic methods.
METHODS
The authors retrospectively reviewed the records of 287 consecutive patients who had undergone endoscopic endonasal TSR for NFPMAs at their institution in the period from 2005 to 2011. Fifty patients who had undergone revision TSR were retrospectively matched for age, sex, and duration of follow-up to 46 patients who had undergone primary TSR. Medical and surgical complications were documented, and Kaplan-Meier analysis was performed to assess rates of radiological progression-free survival (PFS).
RESULTS
The median follow-up periods were 45 and 46 months for the primary and revision TSR groups, respectively. There were no significant differences between the primary and revision groups in rates of new neurological deficit (0 in each), vascular injury (2% vs 0), postoperative CSF leak (6% vs 2%), transient diabetes insipidus (DI; 15% vs 12%), chronic DI (2% vs 2%), chronic sinusitis (4% vs 6%), meningitis (2% vs 2%), epistaxis (7% vs 0), or suprasellar hematoma formation (0 vs 2%). However, patients who underwent primary TSR had significantly higher rates of syndrome of inappropriate antidiuretic hormone (SIADH; 17% vs 4%, p = 0.04). Patients who underwent primary operations also had significantly higher rates of gross-total resection (GTR; 63% vs 28%, p < 0.01) and significantly lower rates of adjuvant radiotherapy (13% vs 42%, p < 0.01). Radiological PFS rates were similar at 2 years (98% vs 96%) and 5 years (87% vs 80%, p = 0.668, log-rank test).
CONCLUSIONS
Patients who underwent primary TSR of NFPMAs experienced higher rates of SIADH than those who underwent revision TSR. Patients who underwent revision TSR were less likely to have GTR of their tumor, although they still had a PFS rate similar to that in patients who underwent primary TSR. This finding may be attributable to an increased rate of adjuvant radiation treatment to subtotally resected tumors in the revision TSR group.
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Affiliation(s)
| | | | | | | | | | - Spencer C. Payne
- 2Otolaryngology-Head and Neck Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Edward R. Laws
- 3Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Minniti G, Osti MF, Niyazi M. Target delineation and optimal radiosurgical dose for pituitary tumors. Radiat Oncol 2016; 11:135. [PMID: 27729088 PMCID: PMC5057503 DOI: 10.1186/s13014-016-0710-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 10/01/2016] [Indexed: 11/10/2022] Open
Abstract
Stereotactic radiosurgery (SRS) delivered as either single-fraction or multi-fraction SRS (2–5 fractions) is frequently employed in patients with residual or recurrent pituitary adenoma. The most common delivery systems used for SRS include the cobalt-60 system Gamma Knife, the CyberKnife (CK) robotic radiosurgery system, or a modified conventional radiotherapy machine (linear accelerator, LINAC). Tumor control and normalization of hormone hypersecretion have been reported in 75–100 % and 25–80 % of patients, respectively. Hypopituitarism is the most commonly reported late complication of radiation treatment, whereas other toxicities occur less frequently. We have provided an overview of the recent available literature on SRS in patients with a pituitary adenoma. Critical aspects of pituitary irradiation, including target delineation and doses to organs at risk, optimal radiation dose, as well as the long-term efficacy and toxicity of SRS for either nonfunctioning or secreting pituitary adenomas are discussed. Single-fraction SRS represents an effective treatment for patients with a pituitary adenoma; however, caution should be used for lesions > 2.5–3 cm in size and/or involving the anterior optic pathway. Future studies will be necessary to optimize target doses and critical organ dose constrains in order to reduce the long-term toxicity of treatments while maintaining high efficacy.
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Affiliation(s)
- Giuseppe Minniti
- Unit of Radiation Oncology, Sant' Andrea Hospital, University Sapienza, Rome, Italy. .,IRCCS Neuromed, Pozzilli (IS), Italy.
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Sokolowski JD, Cohen-Inbar O, Sheehan JP. Radiosurgery for infundibulum adenoma: stalk dose implications. Acta Neurochir (Wien) 2016; 158:1697-700. [PMID: 27435739 DOI: 10.1007/s00701-016-2894-1] [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: 06/20/2016] [Accepted: 07/04/2016] [Indexed: 10/21/2022]
Abstract
Treating pituitary adenomas in the infundibulum with stereotactic radiosurgery (SRS), achieving tumor volume control while preserving pituitary endocrine function and visual function, is challenging. We present a case of a recurrent remnant infundibular lesion treated with Gamma Knife surgery (GKS). The mass was treated with microsurgical resection twice, and the residual stalk lesion was treated with single-session SRS employing a margin dose of 15 Gy to the infundibulum. Five years after GKS, tumor regression persists without visual dysfunction or hypopituitarism. Radiosurgical doses of 30 Gy to the pituitary stalk may be tolerated by patients while maintaining endocrine function.
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Abstract
PURPOSE OF REVIEW For the residual/recurrent pituitary adenomas, stereotactic radiosurgery (SRS) plays an important role in long-term tumor control and, for secretory adenomas, endocrine remission. The purpose of this review is to address the advances in SRS technique and detail the latest treatment strategies for various types of pituitary adenomas with a focus on recently published literature. RECENT FINDINGS From recent publications, SRS may be considered as an upfront treatment in patients with an adenoma that resides largely in the cavernous sinus and for whom resection is unlikely to produce substantial reduction in the overall tumor volume. Early treatment (<6 months after prior resection) with SRS appears to decrease the rate of tumor progression of subtotally resected nonfunctioning pituitary macroadenomas. Some types of adenomas may appear more aggressive with a high recurrence rate, for example, silent corticotroph pituitary adenomas, or sparsely granulated somatotroph-cell adenomas, may be indicated for a high-radiation dose. Finally, whole-sellar radiation and fractionated SRS are the alternative strategies, and may be indicated for challenging cases. SUMMARY The role of SRS for the pituitary adenoma is well established, and the treatment strategy is increasingly individualized based upon tumor histology, location, and volume. Hypopituitarism is the most complicated and can occur even years after SRS.
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Affiliation(s)
- Cheng-Chia Lee
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA
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37
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Lenders N, Ikeuchi S, Russell AW, Ho KK, Prins JB, Inder WJ. Longitudinal evaluation of the natural history of conservatively managed nonfunctioning pituitary adenomas. Clin Endocrinol (Oxf) 2016; 84:222-228. [PMID: 26291181 DOI: 10.1111/cen.12879] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 07/29/2015] [Accepted: 08/13/2015] [Indexed: 11/29/2022]
Abstract
CONTEXT The optimal management of nonfunctioning pituitary adenomas presenting without symptomatic mass effect remains uncertain. The objective of this study was to elucidate the natural history of nonfunctioning pituitary adenomas managed conservatively. DESIGN Volumetric evaluation of tumour growth in serial pituitary MRI scans by a single observer and retrospective review of changes in pituitary function. PATIENTS Patients with nonfunctioning pituitary adenomas who underwent at least 2 serial pituitary MRI scans over ≥6 months between 2003 and 2013 prior to any intervention. MEASUREMENTS Primary end-point was a ≥20% increase in volume or surgery. Secondary end-points were rate of pituitary dysfunction and pituitary apoplexy. RESULTS Fifty nonfunctioning pituitary adenomas (23 macroadenomas and 27 microadenomas, mean age 49, range 17-85 years) were identified. Mean follow-up was 36 months (range 6-79). An increase in volume occurred in macroadenomas (P < 0·01) but not in microadenomas (P = 0·44). A ≥20% increase in volume occurred in nine of 23 macroadenomas compared with two of 27 microadenomas (P < 0·05). Five macroadenomas (one with new visual field defect) and one microadenoma proceeded to surgery (P = 0·08). Hormone deficiency was present in four of 24 macroadenomas vs 0 of 27 microadenomas (P < 0·05) at baseline, while new hormone deficiency developed in only two macroadenomas during follow-up. Pituitary apoplexy occurred in one microadenoma. A growth rate of >10 mm3 /month assessed at approximately 2 years of follow-up among the macroadenoma group was highly predictive (sensitivity and specificity of 90%) of a ≥20% increase in volume or surgery. CONCLUSIONS Nonfunctioning pituitary macroadenomas have a greater tendency to grow and require surgical intervention while microadenomas rarely progress.
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Affiliation(s)
- Nèle Lenders
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Seira Ikeuchi
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Anthony W Russell
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Ken Ky Ho
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Johannes B Prins
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Pomeraniec IJ, Dallapiazza RF, Xu Z, Jane JA, Sheehan JP. Early versus late Gamma Knife radiosurgery following transsphenoidal resection for nonfunctioning pituitary macroadenomas: a matched cohort study. J Neurosurg 2015; 125:202-12. [PMID: 26517773 DOI: 10.3171/2015.5.jns15581] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECT Gamma Knife radiosurgery (GKRS) is frequently employed to treat residual or recurrent nonfunctioning pituitary macroadenomas. There is no consensus as to whether GKRS should be used early after surgery or if radiosurgery should be withheld until there is evidence of radiographic progression of tumor. METHODS This is a retrospective review of patients with nonfunctioning pituitary macroadenomas who underwent transsphenoidal surgery followed by GKRS between 1996 and 2013 at the University of Virginia Health System. Patients were stratified based on the interval between resection and radiosurgery. Operative results and imaging and clinical outcomes were compared across groups following early (≤ 6 months) or late (> 6 months) radiosurgery. RESULTS Sixty-four patients met the study criteria and were grouped based on early (n = 32) or late (n = 32) GKRS following transsphenoidal resection. There was a greater risk of tumor progression after GKRS in the late radiosurgical group (p = 0.027) over a median radiographic follow-up period of 68.5 months. Furthermore, there was a significantly higher occurrence of post-GKRS endocrinopathy in the late radiosurgical cohort (p = 0.041). Seventeen percent of patients without endocrinopathy in the early cohort developed new endocrinopathies during the follow-up period versus 64% in the late cohort (p = 0.036). This difference was primarily due to a significantly higher rate of tumor growth during the observation period of the late treatment cohort (p = 0.014). Of these patients with completely new endocrinopathies, radiation-associated pituitary insufficiency developed in 1 of 2 patients in the early group and in 3 of 7 (42.9%) patients in the late group. CONCLUSIONS Early treatment with GKRS appears to decrease the rate of radiographic and symptomatic progression of subtotally resected nonfunctioning pituitary macroadenomas compared with late GKRS treatment after a period of expectant management. Delaying radiosurgery may place the patient at increased risk for adenoma progression and endocrinopathy.
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Affiliation(s)
- I Jonathan Pomeraniec
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Robert F Dallapiazza
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Zhiyuan Xu
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - John A Jane
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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Mak HKF, Lai SW, Qian W, Xu S, Tong E, Vance ML, Oldfield E, Jane J, Sheehan J, Yau KKW, Wintermark M. Effective time window in reducing pituitary adenoma size by gamma knife radiosurgery. Pituitary 2015; 18:509-17. [PMID: 25261330 DOI: 10.1007/s11102-014-0603-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Although the effectiveness of gamma knife radiosurgery (GKRS) in controlling the size of pituitary adenomas has been well demonstrated in many studies, the time period in which significant changes in tumor size occurs has been investigated in a limited fashion. It is important to determine the therapeutic window of GKRS in treating pituitary adenomas, i.e., the effective timeframe during which significant size reduction of these tumors occurs, so that alternative treatments such as further GKRS or microsurgery might be prescribed in a timely manner if clinically indicated. METHODS This was a nested sample of an ongoing local cohort study on GKRS for pituitary adenomas at the University of Virginia. Magnetic resonance imaging (MRI) using dedicated sequences was employed. Only patients with a baseline MRI (TP0) and at least 1 follow-up study performed in the University Hospital after GKRS were included. The follow-up scans were performed at five time-points (TP1-TP5) which were 6, 12, 24, 36 and 48 months after GKRS. The dimensional indices of the tumors were measured in three orthogonal planes, i.e., transverse (TR), antero-posterior (AP) and cranio-caudal (CC). The volumes of the tumors were estimated by using the following formula: [Formula: see text]. Tumor volume decrease by more than 25% from baseline was considered as 'shrinkage', <25% tumor size increase or decrease was considered 'static', and more than 25% increase as 'increment'. Our cohort consisted of 21 patients, with functioning adenomas in 13 subjects i.e. six adrenocorticotrophic hormone (ACTH)-secreting and seven growth hormone (GH)-secreting, and non-functioning (NF) adenomas in eight subjects. RESULTS In 26 adenomas (8 ACTH, 9 GH and 9 NF), tumor control (tumor shrinkage or static) were achieved in 21 tumors (80.8%); 89, 75, and 78% for GH-secreting, ACTH-secreting and NF adenomas respectively, at the end of the 4-year follow-up period. Analysis of variance showed significant differences of GKRS margin dose among different types of tumors (p = 0.013), but not of baseline tumor volumes (p = 0.240). Logistic regression analysis showed no significant association of margin dose, baseline volume or tumor type with the tumor control outcome. Comparison of tumor change using dimensional indices relative to the base time point (TP0) showed that in the sample there was an average reduction of 1.290 mm at TP1 (6 months) with p values 0.155 (parametric t test) and 0.098 (non-parametric Wilcoxon signed-ranked test) respectively, showing a moderate reduction in tumor dimensional indices. The change in dimensional indices at later time points (TP2-TP5) showed an average reduction ranging from 1.930 to 2.471 mm. Significant reduction in the mean dimensional indices was firstly observed at TP2 (1 year) with p values 0.013 (t test) and 0.018 (Wilcoxon signed-rank test). Such scale of reduction in the dimensional indices appeared to be maintained along the time axis (from TP2 to TP5). CONCLUSIONS Significant decrease in tumor dimensional indices tended to occur at 1 year post-GKRS. Although to a lesser extent, such decrease in dimensional indices continued up to the end of our follow-up period.
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Affiliation(s)
- Henry Ka-Fung Mak
- Department of Diagnostic Radiology, University of Hong Kong, Hong Kong Special Administrative Region, China
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Hasegawa T, Shintai K, Kato T, Iizuka H. Stereotactic Radiosurgery as the Initial Treatment for Patients with Nonfunctioning Pituitary Adenomas. World Neurosurg 2015; 83:1173-9. [PMID: 25700971 DOI: 10.1016/j.wneu.2015.01.054] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 01/18/2015] [Accepted: 01/28/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this study was to confirm the efficacy and safety of stereotactic radiosurgery as the initial treatment for patients with nonfunctioning pituitary adenomas (NFPAs) and to decide the optimum dose to achieve long-term tumor control as well as preservation of pituitary endocrine function. METHODS The study was a single-center retrospective analysis of 16 patients with primary NFPAs that were treated with gamma knife surgery (GKS). Fifteen of 16 NFPAs were growing to the suprasellar region and slightly compressing or very close to the optic apparatus. Initial GKS was selected to avoid visual disturbance caused by further tumor growth that would require surgical resection under general anesthesia. The median tumor volume was 2.0 cm(3), and the median tumor margin dose was 15 Gy. RESULTS The median clinical follow-up period was 98 months. The last follow-up images demonstrated tumor regression in 15 patients and stable tumor in 1. No patient developed tumor progression. One patient who had pituitary apoplexy before treatment required hormone replacements 2 years after GKS. The other patients did not experience pituitary insufficiency requiring hormone-replacement therapy during the clinical follow-up period. No patient developed cranial nerve injury or radiation-induced neoplasm. CONCLUSIONS GKS is a safe and effective treatment option in patients with primary NFPAs, especially for patients with advanced age or comorbidity. Attention should be paid to late adverse radiation effects such as hypopituitarism, optic neuropathy, and radiation-induced neoplasms. However, stereotactic radiosurgery with a conformal treatment plan sparing the normal pituitary gland will contribute to avoidance of such complications as well as achievement of long-term tumor control.
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Affiliation(s)
- Toshinori Hasegawa
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan.
| | - Kazunori Shintai
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Takenori Kato
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
| | - Hiroshi Iizuka
- Department of Neurosurgery, Gamma Knife Center, Komaki City Hospital, Komaki, Japan
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Minniti G, Clarke E, Scaringi C, Enrici RM. Stereotactic radiotherapy and radiosurgery for non-functioning and secreting pituitary adenomas. Rep Pract Oncol Radiother 2014; 21:370-8. [PMID: 27330422 DOI: 10.1016/j.rpor.2014.09.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/28/2014] [Accepted: 09/16/2014] [Indexed: 11/18/2022] Open
Abstract
Radiotherapy (RT) is frequently employed in patients with residual or recurrent pituitary adenoma with excellent rates of tumor control and remission of hormonal hypersecretion. Advances in RT have improved with the use of stereotactic techniques either as fractionated stereotactic radiotherapy (FSRT) or stereotactic radiosurgery (SRS), all aiming to improve the dose distribution to the tumor while reducing the amount of normal brain receiving significant doses of radiation. We provide an overview of the recent published literature on the long-term efficacy and adverse effects of stereotactic irradiation in nonfunctioning and secreting pituitary adenomas. Both techniques are associated with excellent clinical outcomes; however, advantages and drawbacks of each of these techniques in terms of local control, hormonal excess normalization, and radiation-induced toxicity remain a matter of debate. In clinical practice, single-fraction SRS may represent a convenient approach to patients with small and medium-sized pituitary adenoma away at least 2 mm from the optic chiasm, whereas FSRT is preferred over SRS for lesions >2.5-3 cm in size and/or involving the anterior optic pathway.
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Affiliation(s)
- Giuseppe Minniti
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy; IRCCS Neuromed, Pozzilli, IS, Italy
| | - Enrico Clarke
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Claudia Scaringi
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Riccardo Maurizi Enrici
- Department of Radiation Oncology, Sant' Andrea Hospital, University of Rome Sapienza, Rome, Italy
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Dallapiazza RF, Grober Y, Starke RM, Laws ER, Jane JA. Long-term Results of Endonasal Endoscopic Transsphenoidal Resection of Nonfunctioning Pituitary Macroadenomas. Neurosurgery 2014; 76:42-52; discussion 52-3. [DOI: 10.1227/neu.0000000000000563] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Several studies report early results of endoscopic endonasal transsphenoidal surgery; however, none discuss long-term outcome measures such as tumor recurrence rates and the need for additional surgical procedures.
OBJECTIVE:
To discuss the long-term outcomes after endoscopic endonasal transsphenoidal surgery for nonfunctioning pituitary macroadenomas.
METHODS:
This is a retrospective study. Patients were included only if they had at least 5 years of clinical and imaging follow-up after surgery.
RESULTS:
Eighty patients met the study criteria. Grossly complete resection was achieved in 71% of patients. Knosp grade 0 to 2 tumors and tumor with volumes <10 cm3 were significantly more likely to have received a grossly complete resection. There were 7 recurrences (12%) in patients who had received grossly complete resections, with a mean time to recurrence of 53 months. Among the 23 patients who had subtotal resections, 11 (61%) progressed radiographically, and 3 (17%) had symptomatic progression. Knosp score, surgical and radiographic evidence of invasion, and preoperative visual deficits were predictive of recurrence in a univariate analysis, but Knosp grade was the only independent predictor in a multivariate analysis. Kaplan-Meier analysis projected a 10-year progression-free survival rate of 80% and 21% for patients with gross total resections and subtotal resections, respectively.
CONCLUSION:
At the long-term follow-up, 12% of patients had recurrent tumors after grossly complete resection. Recurrent or residual tumors were treated with either repeat surgery or Gamma Knife radiosurgery. Rates of complete resection, postoperative surgical and endocrinological complications, and additional surgical procedures are similar to previously published reports after microscopic transsphenoidal surgery.
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Affiliation(s)
- Robert F. Dallapiazza
- University of Virginia Health System, Department of Neurosurgery, Charlottesville, Virginia
| | - Yuval Grober
- University of Virginia Health System, Department of Neurosurgery, Charlottesville, Virginia
| | - Robert M. Starke
- University of Virginia Health System, Department of Neurosurgery, Charlottesville, Virginia
| | - Edward R. Laws
- Brigham and Women's Hospital, Pituitary/Neuroendocrine Center, Boston, Massachusetts
| | - John A. Jane
- University of Virginia Health System, Department of Neurosurgery, Charlottesville, Virginia
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Sheehan JP, Yen CP, Lee CC, Loeffler JS. Cranial stereotactic radiosurgery: current status of the initial paradigm shifter. J Clin Oncol 2014; 32:2836-46. [PMID: 25113762 PMCID: PMC4152711 DOI: 10.1200/jco.2013.53.7365] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The concept of stereotactic radiosurgery (SRS) was first described by Lars Leksell in 1951. It was proposed as a noninvasive alternative to open neurosurgical approaches to manage a variety of conditions. In the following decades, SRS emerged as a unique discipline involving a collegial partnership among neurosurgeons, radiation oncologists, and medical physicists. SRS relies on the precisely guided delivery of high-dose ionizing radiation to an intracranial target. The focused convergence of multiple beams yields a potent therapeutic effect on the target and a steep dose fall-off to surrounding structures, thereby minimizing the risk of collateral damage. SRS is typically administered in a single session but can be given in as many as five sessions or fractions. By providing an ablative effect noninvasively, SRS has altered the treatment paradigms for benign and malignant intracranial tumors, functional disorders, and vascular malformations. Literature on extensive intracranial radiosurgery has unequivocally demonstrated the favorable benefit-to-risk profile that SRS affords for appropriately selected patients. In a departure from conventional radiotherapeutic strategies, radiosurgical principles have recently been extended to extracranial indications such as lung, spine, and liver tumors. The paradigm shift resulting from radiosurgery continues to alter the landscape of related fields.
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Affiliation(s)
- Jason P Sheehan
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Chun-Po Yen
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Cheng-Chia Lee
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jay S Loeffler
- Jason P. Sheehan, Chun-Po Yen, Cheng-Chia Lee, University of Virginia, Charlottesville, VA; Jay S. Loeffler, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Berkmann S, Schlaffer S, Nimsky C, Fahlbusch R, Buchfelder M. Intraoperative high-field MRI for transsphenoidal reoperations of nonfunctioning pituitary adenoma. J Neurosurg 2014; 121:1166-75. [PMID: 25127413 DOI: 10.3171/2014.6.jns131994] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The loss of anatomical landmarks, frequently invasive tumor growth, and tissue changes make transsphenoidal reoperation of nonfunctioning pituitary adenomas (NFAs) challenging. The use of intraoperative MRI (iMRI) may lead to improved results. The goal of this retrospective study was to evaluate the impact of iMRI on transsphenoidal reoperations for NFA. METHODS Between September 2002 and July 2012, 109 patients underwent reoperations in which 111 transsphenoidal procedures were performed and are represented in this study. A 1.5-T Magnetom Sonata Maestro Class scanner (Siemens) was used for iMRI. Follow-up iMRI scans were acquired if gross-total resection (GTR) was suspected or if no further removal seemed possible. RESULTS Surgery was performed for tumor persistence and regrowth in 26 (23%) and 85 (77%) patients, respectively. On the initial iMRI scans, GTR was confirmed in 19 (17%) patients. Remnants were located as follows: 65 in the cavernous sinus (71%), 35 in the suprasellar space (38%), 9 in the retrosellar space (10%). Additional resection was possible in 62 (67%) patients, resulting in a significant volume reduction and increased GTR rate (49%). The GTR rates of invasive tumors on initial iMRI and postoperative MRI (poMRI) were 7% and 25%, respectively. Additional remnant resection was possible in 64% of the patients. Noninvasive tumors were shown to be totally resected on the initial iMRI in 31% of cases. After additional resection for 69% of the procedures, the GTR rate on poMRI was 75%. Transcranial surgery to resect tumor remnants was indicated in 5 (5%), and radiotherapy was performed in 29 (27%) patients. After GTR, no recurrence was detected during a mean follow-up of 2.2 ± 2.1 years. CONCLUSIONS The use of iMRI in transsphenoidal reoperations for NFA leads to significantly higher GTR rates. It thus prevents additional operations and reduces the number of tumor remnants. The complication rates do not exceed the incidences reported in the literature for primary transsphenoidal surgery. If complete tumor resection is not possible, iMRI guidance can facilitate tumor volume reduction.
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Affiliation(s)
- Sven Berkmann
- Department of Neurosurgery, University Hospital Erlangen, Erlangen
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Unyielding progress: recent advances in the treatment of central nervous system neoplasms with radiosurgery and radiation therapy. J Neurooncol 2014; 119:513-29. [PMID: 25119001 DOI: 10.1007/s11060-014-1501-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
Abstract
In the past decade, our understanding of the roles of external beam radiotherapy (EBRT) and stereotactic radiosurgery (SRS) in the management of brain tumors has dramatically improved. To highlight the changes and contemporary treatment approaches, we review the indications and outcomes of ionizing radiation for benign intracranial tumors and brain metastases. For nonfunctioning pituitary adenomas, SRS is able to achieve radiographic tumor control in at least 90 % of cases. The rate of SRS-induced endocrine remission for functioning pituitary adenomas depends on the tumor subtype, but it is generally lower than the rate of radiographic tumor control. The most common complications from pituitary adenoma SRS treatment are hypopituitarism and cranial neuropathies. SRS has become the preferred treatment modality for vestibular schwannomas and skull base meningiomas less than 3 cm in size. Large vestibular schwannomas and meningiomas remain best managed with initial surgical resection or EBRT for surgically ineligible patients. For small to moderately sized brain metastases, there has been a shift toward treatment of newly diagnosed patients with SRS alone due to similar local control rates compared with surgical resection. RCTs have shown combined SRS and whole brain radiation therapy (WBRT) for brain metastases to decrease rates of local and distant intracranial recurrence compared to SRS alone. However, the improved intracranial control comes at the expense of poorer neurocognitive outcomes and without prolonging overall survival. Therefore, WBRT is generally reserved for salvage therapy. While EBRT has been frequently supplanted by SRS for the treatment pituitary adenomas and brain metastases, it still proves useful in selected cases of large lesions which are not amenable to surgical debulking or for those with widespread disease, poor performance status, and short life expectancy. In recent years, the scope of SRS has extended beyond the intracranial space to include extradural and intradural spinal tumors.
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Lee CC, Kano H, Yang HC, Xu Z, Yen CP, Chung WY, Pan DHC, Lunsford LD, Sheehan JP. Initial Gamma Knife radiosurgery for nonfunctioning pituitary adenomas. J Neurosurg 2014; 120:647-54. [DOI: 10.3171/2013.11.jns131757] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Nonfunctioning pituitary adenomas (NFAs) are the most common type of pituitary adenoma and, when symptomatic, typically require surgical removal as an initial means of management. Gamma Knife radiosurgery (GKRS) is an alternative therapeutic strategy for patients whose comorbidities substantially increase the risks of resection. In this report, the authors evaluated the efficacy and safety of initial GKRS for NFAs.
Methods
An international group of three academic Gamma Knife centers retrospectively reviewed outcome data in 569 patients with NFAs.
Results
Forty-one patients (7.2%) underwent GKRS as primary management for their NFAs because of an advanced age, multiple comorbidities, or patient preference. The median age at the time of radiosurgery was 69 years. Thirty-seven percent of the patients had hypopituitarism before GKRS. Patients received a median tumor margin dose of 12 Gy (range 6.2–25.0 Gy) at a median isodose of 50%. The overall tumor control rate was 92.7%, and the actuarial tumor control rate was 94% and 85% at 5 and 10 years postradiosurgery, respectively. Three patients with tumor growth or symptom progression underwent resection at 3, 3, and 96 months after GKRS, respectively. New or worsened hypopituitarism developed in 10 patients (24%) at a median interval of 37 months after GKRS. One patient suffered new-onset cranial nerve palsy. No other radiosurgical complications were noted. Delayed hypopituitarism was observed more often in patients who had received a tumor margin dose > 18 Gy (p = 0.038) and a maximum dose > 36 Gy (p = 0.025).
Conclusions
In this study, GKRS resulted in long-term control of NFAs in 85% of patients at 10 years. This experience suggests that GKRS provides long-term tumor control with an acceptable risk profile. This approach may be especially valuable in older patients, those with multiple comorbidities, and those who have endocrine-inactive tumors without visual compromise due to mass effect of the adenoma.
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Affiliation(s)
- Cheng-Chia Lee
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital; and
- 4School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hideyuki Kano
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Huai-Che Yang
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital; and
- 4School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Zhiyuan Xu
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Chun-Po Yen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Wen-Yuh Chung
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital; and
- 4School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - David Hung-Chi Pan
- 3Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital; and
- 4School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - L. Dade Lunsford
- 2Department of Neurosurgery, University of Pittsburgh, Pennsylvania
| | - Jason P. Sheehan
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Cámara Gómez R. Tumores hipofisarios no funcionantes: actualización 2012. ACTA ACUST UNITED AC 2014; 61:160-70. [DOI: 10.1016/j.endonu.2013.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 03/27/2013] [Accepted: 04/02/2013] [Indexed: 01/10/2023]
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Pekic S, Popovic V. Alternative causes of hypopituitarism: traumatic brain injury, cranial irradiation, and infections. HANDBOOK OF CLINICAL NEUROLOGY 2014; 124:271-90. [PMID: 25248593 DOI: 10.1016/b978-0-444-59602-4.00018-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Hypopituitarism often remains unrecognized due to subtle clinical manifestations. Anterior pituitary hormone deficiencies may present as isolated or multiple and may be transient or permanent. Traumatic brain injury (TBI) is recognized as a risk factor for hypopituitarism, most frequently presenting with isolated growth hormone deficiency (GHD). Data analysis shows that about 15% of patients with TBI have some degree of hypopituitarism which if not recognized may be mistakenly ascribed to persistent neurologic injury and cognitive impairment. Identification of predictors for hypopituitarism after TBI is important, one of them being the severity of TBI. The mechanisms involve lesions in the hypothalamic-pituitary axis and inflammatory changes in the central nervous system (CNS). With time, hypopituitarism after TBI may progress or reverse. Cranial irradiation is another important risk factor for hypopituitarism. Deficiencies in anterior pituitary hormone secretion (partial or complete) occur following radiation damage to the hypothalamic-pituitary region, the severity and frequency of which correlate with the total radiation dose delivered to the region and the length of follow-up. These radiation-induced hormone deficiencies are irreversible and progressive. Despite numerous case reports, the incidence of hypothalamic-pituitary dysfunction following infectious diseases of the CNS has been underestimated. Hypopituitarism usually relates to the severity of the disease, type of causative agent (bacterial, TBC, fungal, or viral) and primary localization of the infection. Unrecognized hypopituitarism may be misdiagnosed as postencephalitic syndrome, while the presence of a sellar mass with suprasellar extension may be misdiagnosed as pituitary macroadenoma in a patient with pituitary abscess which is potentially a life-threatening disease.
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Affiliation(s)
- Sandra Pekic
- Faculty of Medicine, University of Belgrade, and Clinic of Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center Belgrade, Belgrade, Serbia
| | - Vera Popovic
- Faculty of Medicine, University of Belgrade, and Clinic of Endocrinology, Diabetes and Metabolic Diseases, University Clinical Center Belgrade, Belgrade, Serbia.
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Transsphenoidal surgical treatment of pituitary adenomas in patients aged 80 years or older. Neurosurg Rev 2013; 37:269-76; discussion 276-7. [DOI: 10.1007/s10143-013-0509-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Revised: 05/27/2013] [Accepted: 07/27/2013] [Indexed: 10/26/2022]
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50
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Ding D, Starke RM, Sheehan JP. Treatment paradigms for pituitary adenomas: defining the roles of radiosurgery and radiation therapy. J Neurooncol 2013; 117:445-57. [DOI: 10.1007/s11060-013-1262-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Accepted: 09/22/2013] [Indexed: 12/25/2022]
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