Radioisotope Hypophysectomy in the Therapy of Advanced Cancer of the Breast

Results obtained in 102 patients give indications on the value of radiological hypophysectomy in the treatment of advanced mammary cancer. The evaluation of the radicality of hypophysectomy is obtained by dosimetric measurements: in each patient the glandular volume submitted to a dose able to produce necrosis was calculated. Hypophysectomy was considered to be total when the whole gland had received a dose of 100,000 rad. The validity of this method was checked in a group of 6 patients where the destroyed hypophyseal volume could be measured by histological methods. Measured and calculated values were found to agree. Since only 87 out of the 102 mammary cancer patients had undergone irradiation of the whole hypophysis with 100,000 rad, the results obtained in the remaining 15 patients are not considered, due to the doubtful total destruction of the gland. Improvement of symptomatology and general conditions was obtained in the 51%, and in some patients (20% of all cases) objective and manifest regressions of the neoplastic changes were observed. Best results were obtained in fertile patients with a total improvement value of the 54 % especially among those patients treated by oophorectomy and ovaro-adrenalectomy followed by hypophysectomy (61% of improvements). As concerns the localizations, the best results were obtained in cases with a single type of localization. As to the histological nature of the neoplasm, results were somewhat more favourable in patients with adenocarcinoma (54 %) than in patients with solid carcinoma (45%). A comparison of the survival curves of patients treated by hypophysectomy, by ovaro-adrenalectomy and by medical or radiological pallation showed a good increase of the survival rates in patients treated by endocrinosurgery. Complications consisted in 4 cases (out of 120 interventions) of traumatic lesions in cranial nerves, ocurred in the first patients treated by such intervention; 5 cases of meningitis which caused the death of the patients; and 32 cases of lasting diabetes insipidus. In other patients a transient occurrence of meningitis and of diabetes insipidus was noted. The conclusion is drawn that the method fulfils in over half of the cases the requisites of a palliative therapy, improving the patients’ conditions without exposing them to remarkable disturbances. On the basis of the exposed criteria, it is to suppose that the selection of patients could improve the results.

Clinical outcome and evidence of high rate post-surgical anterior hypopituitarism in a cohort of TSH-secreting adenoma patients: Might somatostatin analogs have a role as first-line therapy?

PURPOSE

Thyrotropin-secreting pituitary adenomas (TSHomas) represent a rare subtype of pituitary tumors. Neurosurgery (NCH) is still considered the first-line therapy. In this study we aimed to investigate the outcome of different treatment modalities, including first line somatostatin analogs (SSA) treatment, with a specific focus on neurosurgery-related complications.

METHODS

We retrospectively evaluated thirteen patients diagnosed for TSHomas (9 M; age range 27-61). Ten patients had a magnetic resonance evidence of macroadenoma, three with slight visual field impairment. In the majority of patients, thyroid ultrasonography showed the presence of goiter and/or increased gland vascularization. Median TSH value at diagnosis was 3.29 mU/L (normal ranges 0.2-4.2 mIU/L), with median fT4 2.52 ng/dL (0.9-1.7 ng/dL).

RESULTS

Three patients (two microadenoma) were primarily treated with NCH and achieved disease remission, whereas ten patients (nine macroadenomas) were initially treated with SSA. Despite the optimal biochemical response observed during medical treatment in most patients (mean TSH decrease -72%), only two stayed on medical therapy alone, achieving stable biochemical control at the end of the follow-up. The remaining patients (n = 7) underwent NCH later on during their clinical history, followed by radiotherapy or adjuvant SSA treatment in two cases. Noteworthy, five of them developed hypopituitarism. All patients reached a biochemical control, after a multimodal therapeutic approach.

CONCLUSIONS

Neurosurgery ultimately led to complete disease remission or to biochemical control in majority of patients, whereas resulting in a considerable percentage of post-operative complications (mainly hypopituitarism, 50%). In the light of the optimal results unanimously reported for medical treatment with SSA, our experience suggests that a careful evaluation of risk/benefit ratio should be taken into consideration when directing the treatment approach in patients with TSHoma.

Baseline characteristics and effects of ten years of growth hormone (GH) replacement therapy in adults previously treated with pituitary irradiation

CONTEXT

Little is known of the importance of previous irradiation therapy for baseline characteristics and responsiveness to GH replacement in GH deficient (GHD) adults.

OBJECTIVE/DESIGN/PATIENTS

In this prospective, single-centre, open-label study, the effects of 10-year GH replacement were determined in 18 GHD adults that had previously received conventional external fractionated pituitary irradiation therapy (IRR group) and 18 non-irradiated GHD patients (non-IRR group). All patients had adult onset disease and complete deficiency of anterior pituitary hormones and both groups were comparable in terms of age, gender, body mass index (BMI), and waist:hip ratio.

RESULTS

At baseline, IRR patients had higher serum triglyceride (TG) and insulin levels and lower high density lipoprotein (HDL)-cholesterol (HDL-C) level than non-IRR patients (all p<0.05). The 10-year GH replacement improved body composition, bone mass and serum lipid profile without any between-group differences, except for a marginally more beneficial response in serum TG level in the IRR patients. After 10 years, there was no between-group difference in any variable after correction for a higher replacement dose of glucocorticoids in the IRR patients at study end using an analysis of covariance. During the 10-year GH replacement, 5 IRR patients suffered from vascular events (2 fatal) whereas only one non-fatal vascular event occurred in the non-IRR patients.

CONCLUSIONS

IRR patients with GHD display a more severely impaired cardiovascular risk profile at baseline, which was reversed by the 10-year GH replacement after correction for the higher glucocorticoid dose at study end. However, vascular events occurred more frequently in the IRR patients.

Long-term anterior pituitary function in patients with paediatric Cushing's disease treated with pituitary radiotherapy

BACKGROUND/OBJECTIVE

Pituitary radiotherapy (RT) is an effective second-line treatment for paediatric Cushing's disease (CD). Although the short-term effects of pituitary RT are well documented, there are less data on possible long-term sequelae. We report the long-term anterior pituitary function in a cohort of paediatric CD patients treated with pituitary RT.

PATIENTS AND METHODS

Between 1983 and 2006, 12 paediatric CD patients (10 males and 2 females) of mean age 11.4 years at diagnosis (range 6.4-17.4) underwent second-line pituitary RT (45 Gy in 25 fractions), following unsuccessful transsphenoidal surgery. Out of 12, 11 patients were cured by RT (cure interval 0.13-2.86 years) defined by mean serum cortisol of <150 nmol/l on 5-point day curve and midnight sleeping cortisol of <50 nmol/l. Long-term data are available for six male patients, who received RT at the age of 7.0-17.6 years. The mean follow-up from the completion of RT was 10.5 years (6.6-16.5).

RESULTS

At a mean of 1.0 year (0.11-2.54) following RT, GH deficiency (peak GH <1-17.9 mU/l) was present in five out of six patients. On retesting at a mean of 9.3 years (7.6-11.3) after RT, three out of four patients were GH sufficient (peak GH 19.2-50.4 mU/l). Other anterior pituitary functions including serum prolactin in five out of six patients were normal on follow-up. All the six patients had testicular volumes of 20-25 ml at the age of 14.5-28.5 years.

CONCLUSION

This series of patients illustrates the absence of serious long-term pituitary deficiency after RT and emphasises the importance of continued surveillance.

Low grade astrocytoma of the pituitary stalk

A case of low grade astrocytoma (WHO grade II) localised in the pituitary stalk is reported in a 46 year old female who presented with central diabetes insipidus. Six-monthly magnetic resonance imaging was use to determine the progression of the lesion. The patient had a stereotactic biopsy of the lesion 18 months after the initial presentation. The diagnosis was established with the aid of immunohistochemistry. We emphasize the importance of MRI before initiating therapy to evaluate the pituitary stalk lesion and the effectiveness of stereotactic biopsy in securing tissue diagnosis without additional deficit.

Longitudinal study on quality of life in 102 survivors of childhood craniopharyngioma

OBJECTS

We longitudinally analysed functional capacity and quality of life (QoL) in 102 patients with a childhood craniopharyngioma during follow-up.

METHODS

The Fertigkeitenskala Münster-Heidelberg (FMH) ability scale was used for QoL assessment. Multivariate analysis evaluated FMH scores at various time points, examining hypothalamus involvement (HI), body mass index (BMI), degree of resection, tumour progression, relapse and irradiation.

RESULTS AND CONCLUSION

Patients without HI (n=60) self-assessed higher QoL at baseline (p=0.001) and follow-up (p<0.001) than patients with HI (n=42). Only patients without HI evaluated at baseline >12 months after diagnosis showed longitudinal improvement in FMH scores (p=0.040). Rates of incomplete resection and irradiation were higher (p=0.070 and p=0.002 respectively) in patients with HI. In multivariate analysis, only HI, tumour relapse, progression, baseline FMH score, and time between diagnosis and baseline evaluation had independent impact on QoL. HI, tumour progression, and relapse had long-term QoL affects-most notably, severe obesity.

Tumour surveillance imaging in patients with extrapituitary tumours receiving growth hormone replacement

OBJECTIVE

GH replacement is widely used in the management of patients with adult-onset (AO)-GH deficiency (GHD). In most cases, AO-GHD arises as a result of pituitary/peripituitary tumours and/or their treatment, but the effect of GH replacement on recurrence/regrowth of these tumours is unknown. The aim of this study was to examine the effect of GH replacement in a group of patients with primary tumours of the parasellar region, many of which (e.g. craniopharyngioma, glioma or germ cell tumours) might be anticipated to have a higher recurrence rate than secretory and nonsecretory anterior pituitary tumours.

PATIENTS AND DESIGN

We report here our experience of prospective imaging in 50 consecutive patients (21 males; mean age 45.9 years) with nonanterior pituitary parasellar tumours treated with GH. All had severe GHD (peak serum GH 9 mU/l or less on dynamic testing) and were treated with an identical dose-titration regimen to maintain serum IGF-I concentrations between the median and upper end of the age-adjusted normal range. The primary diagnoses were: craniopharyngioma (28), germ cell tumour (8), arachnoid cyst (4), meningioma (4), glioma (4) and mensenchymal tumour (2). External pituitary irradiation had been given to 37 (74%) of patients. Measurements Surveillance imaging (magnetic resonance imaging (MRI) 70%, computed tomography (CT) 16%, both 14%) was performed at baseline (prior to GH), at 6--12 months, and then again yearly or as clinically indicated. Median follow-up was 36 months (range 7--129 months). All images were reviewed by the same radiologist.

RESULTS

Four patients had an apparent increase in tumour volume but in only one patient was it considered necessary to abandon GH replacement. In two of the four cases marginal increases in cystic parasellar tumours were not progressive; and in the fourth case apparent recurrence of a suprasellar germ cell tumour was shown to be acellular fibrous tissue only on biopsy. In all other cases either the appearances were unchanged or the amount of tissue was reduced during long-term follow-up on GH.

CONCLUSIONS

Overall, GH appears safe with respect to tumour recurrence over this time period in this patient group. Comparison with similar prospective series in patients not receiving GH replacement is desirable.

Effect of different therapeutic modalities on spontaneous GH secretion in acromegalic patients

OBJECTIVES

Three major therapeutic modalities (transsphenoidal surgery, radiotherapy and medical therapy) are currently available for acromegaly. Although surgery is regarded as the primary option, 50--60% of macroadenomas require further treatment in the form of radiotherapy and/or medical therapy. Recent studies have suggested that radiotherapy might damage the normal hypothalamic-pituitary axis and also rarely leads to IGF-I normalization. The aims of this study were: (1) to examine the effect of different therapeutic modalities (transsphenoidal surgery, TSS; radiotherapy, RT; medical treatment with somatostatin analogues, SSA) on the daily spontaneous GH secretory pattern (day curve); and (2) to determine the relationship between the characteristics of the GH secretory pattern and the circulating concentration of IGF-I, acid-labile subunit (ALS) and IGFBP-3.

DESIGN AND MEASUREMENTS

Spontaneous GH secretion was evaluated at hourly intervals from 0800 to 1800 h. IGF-I, IGFBP-3 and ALS were measured in basal conditions. The mean and the minimum values obtained from the day curve profile and the coefficient of variation (CV) of single values, which are expressions of the magnitude of the spontaneous secretory pulses, were used for statistical analysis.

PATIENTS

In a group of 45 acromegalic patients (28 women, mean age 51 years, range 26--83 years, and 17 men, mean age 57 years, range 37--78 years) treated with different protocols, including TSS, RT and SSA therapy, we evaluated GH secretion to determine the effect of single treatment options on the spontaneous secretory profile. Subjects were grouped on the basis of different therapeutic modalities: TSS+RT+SSA (group 1), TSS+SSA (group 2), SSA (group 3), TSS (group 4), TSS+RT (group 5). In patients treated with somatostatin analogues (SSA), tests were performed about midway between two injections.

RESULTS

The number of deficiencies of the other pituitary functions (PD) was significantly higher in the groups that underwent RT (groups 1 and 5) than in the other groups; in both cases, P<0.01. No significant differences were observed with regard to the mean GH, IGF-I, ALS or IGFBP-3 among the different treatment groups. A significant difference in the GH nadir was found between groups 2 and 4 (P=0.042) and between groups 3 and 4 (P=0.015). GH CV showed lower values in subjects who underwent RT (groups 1 and 5) than in the other groups. The difference was statistically significant between group 5 and groups 2, 3 and 4 (P<0.05), between group 1 and groups 3 and 4 (P<0.05), and between groups 2 and 4 (P=0.007).

CONCLUSIONS

Our data confirm that radiation therapy decreases GH variability, and that this effect is probably due to hypothalamic damage, as already reported by others. In irradiated patients, a single random sample should therefore be sufficient to evaluate spontaneous GH secretion.

Childhood craniopharyngioma: Vancouver experience

OBJECTIVE

To present our institution's experience in the management of childhood craniopharyngioma since 1982.

METHODS

We retrospectively reviewed the records of all children diagnosed with craniopharyngioma at our children's hospital from its opening in 1982 through to 2003. One neuroradiologist systematically reviewed the neuroimaging. Kaplan-Meier curves were used to analyze the progression-free survival and the overall survival from the time of the first definitive intervention.

CONCLUSIONS

Most children diagnosed with craniopharyngioma are long-term survivors. Survivors suffer from multiple deficits in the long term. A conservative surgical and radiotherapeutic approach and avoiding interventions that are known to cause severe morbidity may minimize these. The use of intracystic bleomycin is a strategy that allows the delay of more aggressive therapies in select patients.

Radical resection of craniopharyngioma

INTRODUCTION

The best management of craniopharyngioma in children remains a controversial topic among neurosurgeons. The two treatments for craniopharyngioma most commonly discussed in the literature are primary total resection and limited resection followed by radiotherapy. Without ignoring the challenging behavior of these tumors, we strongly believe that the first approach in a child with a craniopharyngioma is to attempt total removal. Trying to remove a craniopharyngioma that has been treated previously with other methods is, in our experience, much more dangerous because of adherences of the tumor to vascular and neural structures.

MATERIAL AND METHODS

Between 1988 and 2004, we operated on 153 patients with craniapharyngioma (40% female and 60% male), whose ages at the time of surgery ranged from 15 days to 21 years (mean 10.5 years). Eighty-seven percent of the patients were found to have some visual disturbance and 42% endocrinological alterations. Fifty-four percent of the patients presented hydrocephalus, but only 18% had shunting. Gross total removal was attempted in all patients. Among the 153 patients, the tumor was prechiasmatic in 35 and retrochiasmatic in 112; in ten, these were considered giant forms, and eight had a posterior fossa extension. We performed 84 single and 69 combined approaches.

RESULTS

We achieved total removal in 69% of our patients. None of our patients regarded as having undergone total tumor resection disclosed recurrence after a follow-up of 1-16 years. Radiation therapy was administered in children with subtotal removal. All children underwent total removal, but only 62% of those who underwent subtotal removal had good outcomes. After surgery, endocrinological status worsened in almost all patients, but visual status improved markedly.

CONCLUSIONS

The treatment of choice in craniopharyngioma in childhood is total resection in order to avoid radiation therapy and recurrence. When total resection is not possible, subtotal resection plus radiation therapy is the alternative.

A history of the treatment of craniopharyngiomas

RATIONALE

Nearly 100 years have passed since the first surgical attempt to remove a craniopharyngioma was undertaken, and the management of patients with these tumors continues to both challenge and frustrate those involved with their treatment.

METHODS

By constructing a historical framework from past literature on the treatment of craniopharyngioma, the authors have attempted to document the early and important events in the treatment of these tumors in order to add a historical dimension to their current treatment and to engender a more comprehensive understanding of the modern treatment of craniopharyngioma.

CONCLUSION

The application of radiotherapeutic techniques to the management of craniopharyngioma would begin to complement the role of surgery, but debate would soon emerge as to what constituted the most appropriate management for craniopharyngioma in children.

Final adult height and body mass index after cure of paediatric Cushing's disease

OBJECTIVE

Linear growth data after cure of paediatric Cushing's disease (CD) have been reported infrequently. We evaluated final adult height (FH) and body mass index (BMI) in a cohort of paediatric patients treated successfully for CD.

PATIENTS AND METHODS

Fourteen patients (10 male, age range 6.4-16.6 years) fulfilled the diagnostic criteria for CD. All had had transsphenoidal surgery (TSS), combined with pituitary irradiation (RT) (45 Gy in 25 fractions) in six. All were cured (post-TSS cortisol < 50 nmol/l or mean cortisol post-RT < 150 nmol/l). Subjects analysed had bone ages at diagnosis of < 15 'years' (male) and < 13 'years' (female).

RESULTS

At diagnosis, height SDS was [mean (range)]-2.5 (-4.2 to -0.8) and body mass index (BMI) SDS +2.7 (0.8-5.1). Following cure, 13 patients had GH deficiency (peak GH < 20 mU/l) and were treated with hGH (+ GnRH analogue in four). Height SDS at FH (n = 10) or latest assessment (n = 4) was -1.3 (-3.9-0.2) and increased compared to diagnosis (P < 0.01). The difference between final or latest height SDS and target height SDS was -1.2 (-3.3-0.5), that is less (P < 0.01) than the difference between the height SDS at diagnosis and target height SDS of -2.4 (-3.9 to -0.5). At final height or latest assessment, BMI SDS was +1.7 (0.4-6.2), being decreased compared to diagnosis (P < 0.05) but greater than the normal population (P < 0.01).

CONCLUSION

Catch-up growth was demonstrated in paediatric patients cured from CD, with the majority achieving FH within target height range. Early diagnosis and treatment of GH deficiency is recommended to achieve optimal long-term growth. Excess adiposity remains a potential long-term complication.

[Central diabetes insipidus caused by pituitary metastasis of lung cancer]

A 53-year-old man admitted for thirst, polyposia, and polyuria. Large cell lung cancer T3N2M1 (Stage IV), and central diabetes insipidus caused by pituitary metastasis of lung cancer, were diagnosed. We gave him desmopressin acetate, and chemotherapy with paclitaxel and carboplatin. But pituitary metastasis increased and invaded the hypothalamus. After irradiation of the pituitary and hypothalamus, metastatic focus diminished and desmopressin acetate was tapered.

Infundibuloneurohypophysitis presenting a large sellar-juxtasellar mass: case report

BACKGROUND

Infundibuloneurohypophysitis (INH) is reported to be a self-limiting inflammatory disease involving neurohypophysis. The authors experienced a case of INH presenting a large mass compressing the brain stem.

CASE PRESENTATION

The patient exhibited polyuria followed by left hemiparesis and dysarthria lasting a year. Magnetic resonance imaging showed a large sellar mass extending into the right cavernous sinus and prepontine cistern and compressing pons. Endocrinologically, diabetes insipidus was diagnosed and anterior pituitary function was almost normal. Microscopic examination of the surgical specimen obtained by a transsphenoidal route demonstrated diffuse infiltration of lymphoid cells with predominance of B cells over T cells and the granulation tissue. The patient underwent 40 Gy local radiation because of initial misinterpretation of histologic findings as malignant lymphoma and short-term corticostertoid administration.

CONCLUSION

The mass gradually shrank and the patient has become neurologically intact in 6 months. At this moment, 67 months after the onset, the patient is free from disease and has no other lesion. INH seems to be a clinical entity possessing a wide spectrum from infundibular tumorlet to an aggressive sellar mass trespassing on surrounding structures.

Pituicytoma: Report of Two Cases and Clues Regarding Histogenesis

OBJECTIVE AND IMPORTANCE

The pituicytoma is a rare primary tumor of the neurohypophysis. Although histologically benign, the location and vascular nature of these tumors can make surgical resection difficult. We present a report of two patients with pituicytomas and review the literature regarding treatment and prognosis for this unusual lesion. Possible histogenetic relationships of this tumor with other pituitary neoplasms are presented.

CLINICAL PRESENTATION

Patient 1 was a 45-year-old man who presented with a 5-year history of decreased libido. He was found to have a 2-cm suprasellar mass on a magnetic resonance imaging scan. Patient 2 was a 48-year-old man who presented with multiple endocrine complaints. He was found to have an intrasellar mass on magnetic resonance imaging.

INTERVENTION

Patient 1 underwent a right frontal craniotomy, with a subtotal resection of the suprasellar mass through the lamina terminalis. The residual tumor was treated with fractionated stereotactic radiotherapy. The intrasellar mass in Patient 2 was resected via a transsphenoidal approach. On surveillance magnetic resonance imaging, the tumor was found to have recurred and expanded into the suprasellar space. The patient underwent a right frontal craniotomy for decompression and a subtotal resection of the tumor. The patient experienced a second recurrence 7 years after the initial procedure and was subsequently treated with fractionated stereotactic radiotherapy.

CONCLUSION

Pituicytomas are a distinct form of pituitary gland neoplasia that may recur if subtotally resected. These neurohypophysial tumors may contain a small subpopulation of previously unrecognized bcl-2-immunoreactive cells, whose role in the histogenesis of pituicytoma deserves further study.

Cerebrovascular mortality in patients with pituitary adenoma

OBJECTIVE

To assess cerebrovascular mortality in a UK cohort of patients with pituitary adenoma known to have increased incidence of cerebrovascular accidents (CVA).

METHODS

A total of 334 patients treated at the Royal Marsden Hospital (RMH) between 1962 and 1986 with surgery and postoperative radiotherapy were followed up via the NHS Central Register (NHSCR) to identify deaths and emigrations. The causes of death were assessed by NHSCR-based death certificates and coded according to the 9th revision of ICD. Follow-up was censored at age 85, on emigration or cancellation of NHSCR. Thirteen patients could not be traced. A total of 4982 person-years was accumulated in the cohort. Expected numbers of deaths were computed from the national age-, sex- and period-specific mortality rates for England and Wales.

RESULTS

In the pituitary adenoma cohort, 128 deaths were observed compared to 80.9 expected [relative risk (RR) of death 1.58 (95% CI: 1.32-1.90)]. There were 33 cerebrovascular deaths compared with 8.04 expected (RR 4.11, 95% CI 2.84-5.75). Three deaths were from subarachnoid haemorrhage compared to 0.54 expected (RR 5.51, 95% CI 1.14-16.09). There was an increased cerebrovascular mortality in women (RR 6.93, 95% CI 4.29-10.60) compared to men (RR 2.4, 95% CI 1.24-4.20; P = 0.002) and in patients having debulking surgery (RR 5.19, 95% CI 3.50-7.42) compared to biopsy/no surgery (RR 1.33, 95% CI 0.27-3.88; P = 0.02). The RR in patients with nonsecretory tumours was 3.65 (95% CI 2.26-5.58), compared with 5.23 (95% CI 2.25-10.30) in secretory tumours (P = 0.4). The effect of age at radiotherapy was not significant (P = 0.4).

CONCLUSION

Patients with pituitary adenoma treated with surgery and radiotherapy have an increased risk of cerebrovascular mortality compared to the general population, which mirrors the increased incidence of CVA. The possible risk factors include hypopituitarism, radiotherapy and extent of surgery but none are at present proven causes. The evaluation of new treatment strategies should not only assess intermediate end-points of tumour and endocrine control but should concentrate on long-term survival with particular emphasis on CVA incidence and mortality.

[Cushing's disease and corticotrophic adenoma: results of pituitary microsurgery]

Between November 1994 and June 2001, 194 patients with Cushing's disease underwent transsphenoidal surgery: 167 patients had adenomectomy, 14 had ante hypophysectomy, 5 had subtotal hypophysectomy, 4 had hemihypophysectomy 4 had central hypophysectomy. Complications occurred in 18 patients (9.3%), including 4 deaths (three were apparently not related to surgery). Remission of disease was achieved in 162 of 190 (85.3%) patients analyzed. Surgical failures were associated with lack of pituitary adenoma, size of the tumor and invasiveness. Among patients with confirmed adenomas, the rate of remission was significantly higher (p<0.01) in patients with microadenomas (92.6%) than in patients with macroadenomas (66.7%). Reoperation in 6 failures was followed by remission in 4 cases. The overall remission rate was 87.4%. In the 162 patients with immediate success, duration of follow-up was 10.0 +/- 5.9 years (m +/- DS; median=10.0). Recurrence of the disease occurred in 24 (14.8%) of 162 patients at a mean 4.8 years (range: 0.8-12.0 years). Our longest sustained remission is 25.6 years. Actuarial analysis indicates that the probability of a patient remaining well 12 years after surgery is 80.0%. It is 86.2% in microadenomas versus 52.5% in macroadenomas and 94.5% in the patients with postoperative hypocortisolism versus 59.2% in the others.

Malignant glioma as a secondary malignant neoplasm after radiation therapy for craniopharyngioma: report of a case and review of reported cases

BACKGROUND

The development of a secondary neoplasm in childhood cancer survivors attains growing importance due to the reported excellent survival and therefore the long exposure to potentially carcinogenic effects of treatment.

CASE REPORT

We report a 14-year-old girl in whom a large craniopharyngioma (CP) was diagnosed. After surgery, radiation therapy (RT) was given for residual tumour. Discrete progression necessitated further surgery, resulting in permanent tumour control. Soon after the second surgery hypothalamic-pituitary dysfunction developed together with obesity. Supportive hormone therapy was initiated. Growth hormone (GH) therapy was also given for 15 months. Four years after the diagnosis, a cerebropontine anaplastic astrocytoma WHO grade III was detected, with the main lesion being at the dorsal edge of the irradiated area. The girl died 1 month later from this secondary presumably radiation-induced tumour. Only recently a second child with RT for a CP was diagnosed with malignant glioma in our hospital. CASE REPORTS IN THE LITERATURE: 12 other cases of malignant glioma have been reported after RT for CP. Including our present cases, the mean latency period was 10.7 years (median 9.6 years). However, the shortest latency periods were found in patients who had received GH therapy. In numerous cases, the secondary tumour was seen at the edge of the irradiated volume, and not in the region with the highest absorbed dose.

CONCLUSIONS

Therapy-induced secondary gliomas after treatment of CP or other intracranial tumours are rare but dramatic late events with a very poor prognosis. Including our own 2 patients, we reviewed 14 cases of CP with occurrence of a secondary, probably radiation-induced malignant glioma. The short latency periods for patients treated with GH is remarkable. We therefore suspect that GH therapy may accelerate the development of a secondary brain tumour. We are reluctant to recommend GH therapy in conventionally irradiated CP patients. In order to seriously answer the questions about therapy-induced secondary neoplasms, a life-long follow-up is mandatory for all patients who are survivors of childhood cancer.

Comparison of octreotide acetate LAR and lanreotide SR in patients with acromegaly

BACKGROUND AND OBJECTIVE

The most effective option for the medical treatment of patients with acromegaly is the use of somatostatin analogues. Long-acting depot formulations for intramuscular injection of two somatostatin analogues have recently become available: octreotide acetate LAR (Sandostatin LAR, Novartis Pharma AG) and lanreotide SR (Somatuline, Ipsen Biotech). We wished to compare efficacy of octreotide LAR and lanreotide SR in acromegalic patients.

PATIENTS AND METHODS

A group of 125 patients with acromegaly (67 females; mean age, 47 years; 59 patients had previous pituitary irradiation) from 26 medical centres in France, Spain and Germany were studied. Before the study, all patients had been treated with intramuscular injections of lanreotide SR (mean duration, 26 months) at a dose of 30 mg which was injected every 10 days in 64 and every 14 days in 61 patients, respectively. All patients were switched from lanreotide SR to intramuscular injections of 20 mg of octreotide LAR once monthly for three months. In order to obtain efficacy and safety data of lanreotide SR under study conditions, it was decided to randomly assign at day 1, in a 3 : 1 ratio, the time point of the treatment switch; 27 of the patients were randomly assigned to continue the lanreotide SR treatment for the first 3 months of the study (group A); they were on octreotide LAR 20 mg from month 4-6. The other 98 patients were assigned to be switched to treatment with octreotide LAR 20 mg at day 1 (group B). In group B patients, octreotide LAR treatment was continued until month 6, with an adjustment of the dose based on GH levels obtained at month 3.

RESULTS

The mean GH concentration decreased from 9.6 +/- 1.3 mU/l at the last evaluation on lanreotide SR to 6.8 +/- 1.0 mU/l after three injections of octreotide LAR (P < 0.001). The percentages of patients with mean GH values < or = 6.5 mU/l (2.5 microg/l) and < or = 2.6 mU/l (1.0 microg/l) at the last evaluation on lanreotide SR were 54% and 14%, and these values increased after 3 months treatment with octreotide LAR to 68% and 35% (P < 0.001), respectively. IGF-I levels were normal in 48% at the last evaluation on lanreotide SR and in 65% after 3 months on octreotide LAR (P < 0.001). Patients with pre-study pituitary irradiation had lower mean GH and IGF-I concentrations. But the effects of the treatment change did not differ between the irradiated and the nonirradiated patients. In general both drugs were well tolerated.

CONCLUSION

Octreotide LAR 20 mg administered once monthly was more effective than lanreotide SR 30 mg administered 2 or 3 times monthly in reducing GH and IGF-I in patients with acromegaly.

Growth and endocrine disorders in multisystem Langerhans' cell histiocytosis

INTRODUCTION

Langerhans' cell histiocytosis is a rare disorder, with diabetes insipidus occurring in up to half of patients. Causes of growth failure include the illness itself, treatments used and growth hormone insufficiency.

PATIENTS AND METHODS

We identified all patients with an endocrinopathy secondary to Langerhans' cell histiocytosis (LCH). Growth data were analysed from all patients with multisystem involvement.

RESULTS

Of 144 patients with multisystem LCH, 50 had an endocrinopathy, 49 of whom had diabetes insipidus. Growth hormone insufficiency (GHI) was present in 21 patients, seven of whom had other anterior pituitary deficiencies as well (gonadotrophin deficiency + GHI n = 2, gonadotrophin deficiency + TSH deficiency + GHI n = 2, panhypopituitarism n = 3). GH insufficiency, the development of which appeared to be independent of pituitary radiation, occurred at a median age of 8.3 years (4.7-18 years) and at a median interval of 3.5 years (0-11.8 years) after diagnosis of LCH. The median height SDS at diagnosis of growth hormone insufficiency was -2.9. Thirteen of the patients with growth hormone insufficiency attained final height with a median height SDS of -1.2. The final height SDS of 15 patients without GH insufficiency was closer to target height SDS, but not statistically different from that of the GH insufficient group.

CONCLUSIONS

GH therapy significantly improves growth in GH insufficient patients with Langerhans' cell histiocytosis. Early institution of GH therapy may further improve height outcome. However, most children with Langerhans' cell histiocytosis regardless of endocrine function, failed to reach target height.

Conventional radiotherapy for pituitary tumors

Radiosurgery for pituitary adenomas is clearly attaining a more prominent position in the spectrum of management of these lesions. It is our belief that improvements in radiosurgical technology can significantly enhance the outcome for patients with these lesions.

Treatment of pituitary-dependent Cushing's syndrome: long-term results of unilateral adrenalectomy followed by external pituitary irradiation compared to transsphenoidal pituitary surgery

BACKGROUND

The preferred treatment of Cushing's disease (CD) nowadays is transsphenoidal pituitary surgery (TPS). Prior to TPS, patients at the Leiden University Medical Centre were treated by unilateral adrenalectomy followed by external pituitary irradiation (UAPI). We report on long-term results of both UAPI and TPS and compare remission, relapse rates, and complications.

PATIENTS AND METHODS

A retrospective study was carried out on 130 patients with CD. Patients with pituitary macroadenoma were excluded. Eighty-six and 44 patients underwent UAPI and TPS, respectively. Of these patients, 85 and 41 were evaluable for long-term results.

RESULTS

Remission following UAPI and TPS was identical at 64% (54/85 and 27/41). Cumulative relapse was also comparable - 17% (9/54) and 22% (6/27), respectively, - for UAPI and TPS, although the mean follow-up periods were different - 21.4 years and 8.5 years, respectively. Cumulative disease-free survival curves after UAPI and TPS are identical until 5 years of follow-up, but diverge thereafter indicating more sustained remissions following UAPI (P = 0.17, Wilcoxon statistic). Pituitary dysfunction following UAPI (36%) and pituitary surgery (55%) likewise did not differ significantly. However, pituitary dysfunction was an immediate event after TPS, whereas it developed after a mean interval of 17.8 years following UAPI.Low-dose dexamethasone testing during follow-up had no value in predicting therapeutic outcome.

CONCLUSIONS

The results of unilateral adrenalectomy followed by external pituitary irradiation do not justify that this therapy is totally abandoned in favour of transsphenoidal pituitary surgery. Unilateral adrenalectomy followed by external pituitary irradiation is a valid therapeutic modality for the treatment of Cushing's disease, and could be considered as alternative to bilateral adrenalectomy and under some circumstances to transsphenoidal pituitary surgery.

Prolactin secreting pituitary adenomas: analysis of 429 surgically treated patients, effect of adjuvant treatment modalities and review of the literature

OBJECTIVE

We performed this retrospective analysis to determine the efficacy of surgery and radiotherapy over hormonal and volumetric control of prolactinomas, many of which had failed during dopa-agonist therapy. In the same analysis, the efficiency of topical bromocriptine application as a preliminary study was compared with standard treatment modalities.

MATERIALS AND METHODS

Between 1982-1997, 429 prolactinoma patients who underwent surgery at Hacettepe University Neurosurgery Department and at Bayindir Medical Center were included in this study. All patients were classified according to Hardy's classification scheme and were further divided into 'invasive' and 'non-invasive' groups based on this radiological classification system. The mean follow-up time was 38.4 months. One hundred and thirty five patients had peroperative bromocriptine application into the sellar cavity and these, either receiving radiotherapy (RT) or not, were analysed separately from the other 294 patients. In the early post-operative period, 104 of these patients were given conventional radiotherapy with median dose of 4500 cGy. We focused on the effects of surgery and radiotherapy over volumetric and hormonal tumour control on the basis of invasion characteristics and the early results of topical bromocriptine application in macroprolactinoma patients; and compared our results with the literature.

RESULTS

Statistical analysis revealed that radiotherapy was not effective over hormonal and volumetric tumour control for prolactinomas. We did not observe any correlation to dural invasion of the sellar floor, recurrence, and the disease-free survival time. Topical bromocriptine application seemed to improve the volumetric control in 135 selected macroprolactinoma patients but not hormonal response compared with the standard treatment modalities.

CONCLUSION

Conventional radiotherapy is not as effective as expected for prolactinomas and should not be preferred considering its adverse effects. Tumoural infiltration of the sellar dura mater is not a prognostic criterion for recurrence expectation and, therefore, should not be a criterion for radiotherapy after surgery. After subtotal removal, postoperative dopa-agonist therapy should be considered even if the patient was intolerant or resistant to previous treatment since surgery seems to improve patients' drug tolerance and cooperation due probably to the lower dose requirement. The early results of topical bromocriptine application seem to improve volumetric tumour control but this should not be accepted as a judgement since we need to wait for later results and to expand the sample size for more reliable interpretation.

Pituitary adenomas: results of 684 surgically treated patients and review of the literature

BACKGROUND

The outcome of patients with pituitary adenomas who were treated surgically with or without postoperative radiotherapy was analyzed. The purpose of this study was to determine the factors that strongly influence (A) tumor control, (B) the efficacy of surgery, and (C) radiotherapy based on the hormonal activity of adenomas and its invasion characteristics.

METHODS

Between 1982-1996, 684 patients with the diagnosis of pituitary adenoma were operated on. The mean age was 38 years and the mean follow-up time was 40.5 months. A total of 516 patients who were followed for more than 1 year were studied to analyze the effect of treatment modalities and invasion characteristics on tumor control. There were 297 patients with prolactinomas, 118 patients with somatotropinomas, 45 with corticotropinomas, 17 with mixed adenomas, two with thyrotropinomas, and 205 with null cell adenomas. All patients were classified according to Hardy's modified radiological classification scheme and analyzed in invasive and noninvasive groups individually based on this classification system. In the early postoperative period, 230 of these patients were given conventional radiotherapy with a mean dose of 4400 cGy. The following factors were analyzed for prognostic significance in tumor control: the effects of surgery and radiotherapy based on tumor types and invasion characteristics, the existence of histologically proven invasion of the dura mater overlying the sellar floor, and the early results of topical bromocriptine application in macroprolactinoma patients.

RESULTS

Overall surgical complications and mortality rate were similar to those of large series reported in the literature. Except for the invasive somatotropinomas and null cell adenomas, statistical analysis demonstrated the ineffectiveness of radiotherapy on tumor control. We did not detect any positive correlation between the recurrence rate and mean recurrence time or dural invasion of the sellar floor. Topical bromocriptine application seemed to improve tumor control in 21 selected macroprolactinoma patients.

CONCLUSION

Conventional radiotherapy is not as effective as expected, considering its adverse effects. The increased side effects of radiotherapy in cases with supra-parasellar extension, especially to the optic pathway and hypothalamus, limit its benefits, which could be demonstrated only in invasive somatotropinomas and null cell adenomas. In contrast with our current beliefs, tumoral infiltration of the sellar dura mater is not a prognostic factor for recurrence and therefore should not be a criterion for radiotherapy after surgery. Topical application of bromocriptine into the sellar cavity after tumor removal seems to provide superior results compared with the conventional treatment modalities.

Bone mineral density and markers of bone turnover in young adult survivors of childhood lymphoblastic leukaemia

OBJECTIVE

In order to determine if a serious disease like childhood acute lymphoblastic leukaemia (ALL) and the treatment necessary to cure the patients has long term effects on bone mass, we assessed bone mineral density (BMD) and several parameters involved in bone formation in a group of young adult survivors of ALL.

DESIGN AND PATIENTS

Fourteen male and ten female survivors, treated for ALL in childhood, were cross-sectionally studied, at a mean age of 25.1 years (range 20.1-34.9). All patients, except for two, had received cranial irradiation as part of their treatment (mean radiation dose 2460 cGy).

MEASUREMENTS

Height and weight were measured. Bone mineral density (BMD) was assessed using dual energy X-ray absorptiometry in the lumbar spine, femoral neck, femoral trochanter and at 1/3 distal and ultradistal in the radius. Early morning serum levels of LH, FSH, oestradiol or testosterone, IGF-1 and IGF-BP3 were determined as well as several specific markers of bone turnover.

RESULTS

Mean height, expressed as standard deviation score (SDS) was -1.12, significantly reduced. BMD in the lumbar spine, femoral neck and at 1/3 distal and ultradistal in the radius, was significantly lower compared to the reference population (P < 0.05). No correlation was found between the BMD values and the cumulative dose of administered cytotoxic drugs, the age at diagnosis of ALL or the duration of follow-up. Mean IGF-1 and IGF-BP3 SDS-scores were -1.24 and -0.78 respectively, significantly reduced. GH stimulation tests performed in a subgroup of 9 patients showed an insufficient peak GH response in at least one test in all tested patients. The values of LH, FSH oestradiol or testosterone were within the normal adult range. Serum markers of bone formation and bone resorption were in the normal range, indicating that bone turnover was normal at the time of the study.

CONCLUSIONS

Bone development in patients cured of acute lymphoblastic leukaemia is disturbed, resulting in a significantly reduced bone mineral density. Impaired growth hormone activity, as a long term effect of cranial irradiation, may be one of the underlying causes as well as the illness itself and the administered cytotoxic drugs. Since a reduced bone mineral density predispose patients to osteoporosis, intervention in order to improve bone mass should be considered.

A case study comparing the relative benefit of optimizing beam weights, wedge angles, beam orientations and tomotherapy in stereotactic radiotherapy of the brain

A treatment-planning case study has been performed on a patient with a medium-sized, convex brain tumour. The study involved the application of advanced treatment-plan optimization techniques to improve on the dose distribution of the 'standard plan' used to treat the patient. The standard plan was created according to conventional protocol at the Royal Marsden NHS Trust, and consisted of a three-field (one open and two wedged) non-coplanar arrangement, with field shaping to the beam's-eye view of the planning target volume (PTV). Three optimized treatment plans were created corresponding to (i) the optimization of the beam weights and wedge angles of the standard plan, (ii) the optimization of the beam orientations, beam weights and wedge angles of the standard plan, and (iii) a full fluence tomotherapy optimization of 1 cm wide (at isocentre), 270 degree arcs. (i) and (ii) were created on the VOXELPLAN research 3D treatment-planning system, using in-house developed optimization algorithms, and (iii) was created on the PEACOCK tomotherapy planning system. The downhill-simplex optimization algorithm is used, in conjunction with 'threshold-dose' cost-function terms enabling the algorithm to optimize specific regions of the dose-volume histogram (DVH) curve. The 'beam-cost plot' tool is presented as a visual aid to the selection of beneficial beam directions. The methods and pitfalls in the transfer of plans and patient data between the two planning systems are discussed. Each optimization approach was evaluated, relative to the standard plan, on the basis of DVH and dose statistics in the PTV and organs at risk (OARs). All three optimization approaches were able to improve on the dose distribution of the standard plan. The magnitude of the improvement was greater for the optimized beam-orientation and tomotherapy plans (up to 15% and 30% for the maximum and mean OAR doses). A smaller improvement was observed in the beam-weight and wedge-angle optimized plan (up to 5% and 10% in the maximum and mean OAR doses). In the tomotherapy plan, difficulty was encountered achieving an acceptable homogeneity of dose in the PTV. This was improved by treating the gross tumour volume (GTV) and (PTV - GTV) regions as separate targets in the inverse planning, with the latter region prescribed a slightly higher dose to reduce edge under-dosing. In conclusion, for the medium-sized convex tumour studied, the tomotherapy dose distribution showed a significant improvement on the standard plan, but no significant improvement over a conventional three-field plan where the beam orientations, beam weights and wedge angles had been optimized.

Normal final height and apparent cure after pituitary irradiation for Cushing's disease in childhood: long-term follow-up of anterior pituitary function

Pituitary-dependent Cushing's syndrome is rare in childhood. Two patients are reported who had unsuccessful transsphenoidal microadenomectomy and therefore underwent pituitary radiotherapy. In both patients there was progressive normalization of hypothalamo-pituitary-adrenal function and at 8 and 10 years after radiotherapy their Cushing's syndrome remained in remission clinically and biochemically. Most importantly, they have both achieved adult heights within their respective expected ranges with close clinical observation and replacement growth hormone therapy. Thyroid and gonadal function is normal and neither patient requires any other hormone replacement therapy. Pituitary radiotherapy is thus a safe, effective and well tolerated second-line therapy for paediatric Cushing's disease. Collaboration between the paediatric and adult departments and an experienced radiotherapist contributed to the successful outcome of these two patients.

Pituitary tumours presenting in the elderly: management and outcome

OBJECTIVE

In elderly patients there are few data on the efficacy and safety of pituitary surgery and radiotherapy (DXT). The aim of the present study was to assess the mode of presentation, treatment and outcome of patients > 64 years with a pituitary tumour presenting to a regional neuroendocrine service.

DESIGN

A retrospective case note review of all patients with a pituitary tumour, from 1986 to 1993, was performed with DXT information from computerized records.

PATIENTS

Forty-four patients were identified: median age 70 (65-83) years; 25 males; followed for a mean of 34 (range 0-84) months.

RESULTS

The commonest presenting symptom was with visual disturbance (24 patients) with a further 9 with asymptomatic visual field defects. Five patients had acromegaly and two prolactinoma. Thirty-two patients underwent transsphenoidal surgery (TSS) (with post-operative DXT in 14 cases) and 6 craniotomy. Two patients had DXT as the primary procedure and four were observed. Visual fields improved in 21 of 29 patients. Perioperative complications occurred significantly more often after craniotomy (5/6) than after TSS (6/32) (P < 0.01). Eight patients died during the follow-up period (three deaths tumour related; one death followed DXT).

CONCLUSIONS

Pituitary adenoma is a remediable cause of visual disturbance in the elderly. Most tumours were non-functioning. Age alone is not a contraindication to active treatment particularly with transsphenoidal surgery and radiotherapy.

Corticotrophic macroadenoma of the pituitary associated with hypoadrenalism

A 60-year-old man underwent transfrontal surgery for a macroadenoma of the pituitary which presented with chiasmal compression, and immunohistochemical examination of the resected specimen revealed a corticotrophic tumour. Despite subsequent external irradiation, he was left with a large tumour remnant, which continued to grow. There were no clinical signs of Cushing's syndrome either before or after surgery and 24 h urine excretion of cortisol was not elevated. Plasma ACTH concentrations were marginally raised. However, there was loss of circadian variation in serum cortisol concentrations and administration of high-dose oral dexamethasone was followed by a marked and reproducible rise in both ACTH and cortisol. Two years later he developed symptoms and signs of hypoadrenalism and urine cortisol excretion was low, even though the paradoxical response to dexamethasone was preserved. Treatment with 0.5 mg dexamethasone each day was associated with partial resolution of his symptoms and urine cortisol concentration rose into the normal range. This treatment was maintained until his death in hospital in April 1988. The possible mechanism underlying the association between a corticotrophic tumour and hypoadrenalism are discussed.

Unchanged response to stimulation of pituitary hormone release after serial UV irradiation in men

A group of 24 healthy young men were evaluated before and after serial suberythematous ultraviolet (UV) radiation: group I, control (no irradiation); groups II and III, 12 radiations in 4 weeks with two different spectra (both containing UV-B). Before the first and 2 days after the last exposure all the volunteers were given an intravenous injection of thyrotropin releasing hormone (TRH, protirelin 0.2 mg) and luteinizing hormone releasing hormone (LH-RH, gonadorelin 0.1 mg). The serum concentrations of TSH, follicle stimulating hormone, LH and prolactin were measured at 0, 20, 30, 45 and 60 min by radioimmunoassay. Neither basal nor stimulated levels of the pituitary hormones showed significant changes after UV radiation. The results showed that exposure to suberythematous doses of UV did not influence the regulation of pituitary hormones in these healthy individuals.

Bilateral simultaneous cavernous sinus sampling using corticotropin-releasing hormone in the evaluation of Cushing disease

PURPOSE

To determine whether bilateral, simultaneous, cavernous sinus sampling after corticotropin-releasing hormone (CRH) stimulation offers as accurate detection and lateralization of Cushing disease as inferior petrosal sinus sampling does.

METHODS

Seventeen consecutive patients with hypercortisolism and with high-dose dexamethasone suppression test results suggesting Cushing disease underwent bilateral cavenous sinus sampling with CRH stimulation. The diagnosis of Cushing disease was established in all patients by histologic examination or, if no tumor was found at surgery, by subtotal resection of the gland or radiation therapy resulting in eventual hypocortisolism or normal adrenal function and clinical remission.

RESULTS

The sensitivity of cavenous sinus sampling with and without CRH in detecting Cushing disease was 94% and 71%, respectively. The abnormal side of the pituitary was correctly identified in all patients who had criteria for lateralization, yielding a positive predictive value of 100%.

CONCLUSIONS

This small series suggests that cavernous sinus sampling with CRH is as accurate as inferior petrosal sinus sampling in detecting Cushing disease and perhaps more accurate in lateralizing the abnormality within the pituitary gland.

Results of treatment of pituitary disease in multiple endocrine neoplasia, type I

OBJECTIVE

The aim of the present study was to examine the clinical and pathological features of pituitary disease in patients with multiple endocrine neoplasia, Type I (MEN I) and to assess the prognosis.

METHODS

Fifty-two patients with pituitary disease and MEN I were studied retrospectively. Medical records were reviewed, and all of the patients known to be alive were sent a questionnaire to ascertain current disease status.

RESULTS

In 12 patients, pituitary disease was the initial manifestation of MEN I. The most common lesion was prolactinoma, followed, in frequency, by acromegaly and nonsecretory adenoma. Thirty-four of the patients had surgical treatment at the Mayo Clinic, Rochester, MN, as primary treatment, 3 had radiotherapy, and 12 received no specific therapy. Twelve patients had adjunctive radiotherapy postoperatively. Of the 34 patients receiving surgical treatment, 33 had adenoma and 1 had adenoma and pituitary hyperplasia. Immunocytochemical examination demonstrated that many tumors showed reactivity for more than one pituitary hormone. On survival analysis, no excess pituitary-related mortality was found, either in the surgically treated group or in the group as a whole.

CONCLUSION

On the basis of this study, we conclude that pituitary disease is frequently the initial manifestation of MEN I; that adenomas, particularly prolactinomas, are the rule and hyperplasia is rare; that a significant proportion of tumors are plurihormonal; and that excess pituitary-related mortality is not a factor in patients with MEN I.

Complications in paediatric craniopharyngioma treatment

Forty-eight consecutive children treated for craniopharyngioma at the Juan P. Garrahan National Paediatric Hospital (Buenos Aires, Argentina) from 1988 to 1994 are described. Complications of patients undergoing total resection alone and those undergoing subtotal or partial resection plus radiotherapy were compared. Survival time and quality of life proved more satisfactory in the former group, as there were no recurrences. In contrast, among the latter patients, 53% suffered relapses. Endocrinological complications were similar in the two groups. Postsurgical subdural haematomas were quite frequent and eight patients required treatment for intracranial hypertension. Vascular complications, though less common, led to high morbidity and mortality. There was a considerable incidence of shunt malfunction (80%), arguing against placement of a preoperative shunt, which tended besides to foster postsurgical subdural haematomas.

[Stereotactic intratumoral irradiation of huge craniopharyngioma]

Craniopharyngioma, often with cystic diliatation, is difficult to resect radically. Fifty patients with huge craniopharyngioma (diameter of tumor was over 5 cm) treated with intratumoral irradiation of radioactive isotopes (32P and 90Y) through CT-guided Leksell stereotactic system are reported. The patients were 2 to 69 years of age with the disease of 1- to 12-year duration. Of the 50 patients, 21 had recurrent tumor after craniotomy, 29 without surgery operation before. All tumors were confirmed pathologically. The major clinical symptoms were as follows: visual field defect, headache, vomiting, diabetes insipidus, hemiplegia and growth retardation in juvenile cases. There was no death or serious complications following the treatment procedure. Partial response (> 50% reduction of tumor size on CT scanning with improvement of symptoms and signs) rate of the treatment was 82.0% at one month and 62.0% at 2 to 7 years after treatment.