202 Gamma Knife Pituitary Sblation for Chronic Cancer Pain Control

Neurosurgery ◽  
2017 ◽  
Vol 64 (CN_suppl_1) ◽  
pp. 254-254
Author(s):  
Richard L Weiner
Keyword(s):  
Pituitary Gland ◽  
End Of Life ◽  
Gamma Knife ◽  
Anterior Pituitary ◽  
Gamma Knife Radiosurgery ◽  
High Dose ◽  
Intractable Pain ◽  
Pituitary Insufficiency ◽  
Alcohol Injection ◽  
Pituitary Ablation

Abstract INTRODUCTION Neurosurgeons are, at times, called upon to help manage cancer patients with intractable, progressive pain towards the end of life when the common treatment modalities including high dose narcotics become ineffective. Various neurosurgical interventions, either destructive or neuromodulatory in nature, can offer quality of life enhancement to palliative care. METHODS Gamma Knife radiosurgery was performed focusing on the anterior pituitary gland. RESULTS >7 patients presenting with a variety of metastatic cancer diagnoses in intractable pain were given 200gy of focused cobalt 60 energy to the anterior pituitary with significant improvements in all patients chronic, intractable pain which greatly helped their end of life experience. Patient survival time ranged from 3 months to 2 years. No patient developed pituitary insufficiency. One patient underwent autopsy histologic evaluation of the pituitary gland. No patient developed visual disturbances. CONCLUSION Pituitary ablation for metastatic bony cancer via alcohol injection has been around for years but infrequently thought of as a current treatment. Gamma Knife radiosurgery is a noninvasive method of partial pituitary ablation without signficant side effects.

Gamma knife surgery for cancer pain—pituitary gland—stalk ablation: a multicenter prospective protocol since 2002

2002 ◽  
Vol 97 ◽  
pp. 433-437 ◽  
Author(s):  
Motohiro Hayashi ◽  
Takaomi Taira ◽  
Mikhail Chernov ◽  
Seiji Fukuoka ◽  
Roman Liscak ◽  
...  
Keyword(s):  
Bone Metastasis ◽  
Cancer Pain ◽  
Pituitary Gland ◽  
Gamma Knife ◽  
Pain Control ◽  
Gamma Knife Radiosurgery ◽  
Intractable Pain ◽  
Content Type ◽  
Intractable Cancer Pain ◽  
Fine Print

Object. The authors have treated intractable pain, particularly cancer pain related to bone metastasis, with various protocols. Cancer pain has been treated by gamma knife radiosurgery (GKS), targeted to the pituitary gland—stalk, as an alternative new pain control method. The purpose of this study was to investigate a prospective multicenter protocol to prove the efficacy and the safety of this treatment. Methods. Indications for patient inclusion in this treatment protocol were: 1) pain related to bone metastasis; 2) no other effective pain treatment options; 3) general condition rated as greater than 40 on the Karnofsky Performance Scale; 4) morphine effective for pain control; and 5) no previous treatment with radiation (GKS or conventional radiotherapy) for brain metastasis. The authors at one institution have treated two patients, who suffered from severe cancer pain related to bone metastasis, by using GKS. The target was the pituitary gland. The maximum dose was 160 Gy with one isocenter of an 8-mm collimator, keeping the radiation dose to the optic nerve less than 8 Gy. At another institution two patients were treated in the same way; an additional five patients were treated similarly with targeting of the pituitary gland with two isocenters of 4-mm collimator. In all nine cases, pain resolved without significant complication. Pain relief was observed within several days, and this effect was prolonged until the day that they died. At a follow up of 1 to 24 months, no recurrences and no hormonal dysfunction were observed. Conclusions. Despite insufficient experience, the efficacy and the safety of GKS for intractable pain were demonstrated in nine patients. This treatment has the potential to ameliorate cancer-related pain, and GKS will play a more important role in the treatment of intractable pain. More experience and additional refined study protocols are needed to evaluate which parameters are important, to determine what treatment strategy is the best, and to clarify the safest option for patients with intractable cancer pain.

Effects of gamma knife radiosurgery of pituitary adenomas on pituitary function

2002 ◽  
Vol 97 ◽  
pp. 415-421 ◽  
Author(s):  
Günther Christian Feigl ◽  
Christine Maria Bonelli ◽  
Andrea Berghold ◽  
Michael Mokry
Keyword(s):  
Pituitary Gland ◽  
Gamma Knife ◽  
Pituitary Adenomas ◽  
Gamma Knife Radiosurgery ◽  
Pituitary Function ◽  
Pituitary Insufficiency ◽  
Content Type ◽  
The Mean ◽  
Fine Print ◽  
Stimulating Hormone

Object. The authors undertook a retrospective analysis of the incidence and time course of pituitary insufficiency following gamma knife radiosurgery (GKS) for pituitary adenomas. Methods. Pituitary adenomas in 92 patients were analyzed. There were 61 hormonally inactive tumors, 18 prolactinomas, and nine somatotropic and four adrenocorticotropic adenomas. The mean tumor volume was 3.8 cm3 (range 0.2–14.6 cm3). The mean prescription dose was 15 Gy. The mean prescription isodose was 50.7%. The mean follow-up time was 4.6 years (range 1.2–10 years). The following new or deteriorating insufficiencies that did not require treatment were recorded for the different pituitary axes: follicle-stimulating hormone (FSH)/luteinizing hormone (LH) 19 (20.6%), thyroid-stimulating hormone (TSH) 32 (34.8%), adenocorticotropic hormone (ACTH) 10 (10.9%), and growth hormone (GH) 26 (28.3%). For new insufficiencies or deterioration requiring replacement therapy, the figures were as follows: FSH/LH 20 (21.7%), TSH 22 (23.9%), ACTH eight (8.7%), and GH 12 (13%). Spot dosimetry was performed in 59 patients in the hypothalamic region, the pituitary gland, and pituitary stalk. The pituitary stalks in patients with deterioration of pituitary function received a statistically higher dosage of radiation, 7.7 ± 3.7 Gy compared with 5.5 ± 3 Gy (p = 0.03). Conclusions. The function of the residual normal pituitary gland is less affected following GKS of pituitary adenomas than after fractionated radiotherapy. Nonetheless, increased attention needs to be exercised to reduce the dose to the stalk and pituitary gland to minimize the incidence of these complications.

Gamma knife radiosurgery in patients with advanced breast cancer undergoing bone marrow transplant

2002 ◽  
Vol 97 ◽  
pp. 663-665 ◽  
Author(s):  
Kenneth J. Levin ◽  
Emad F. Youssef ◽  
Andrew E. Sloan ◽  
Rajiv Patel ◽  
Rana K. Zabad ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Advanced Breast Cancer ◽  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
High Dose Chemotherapy ◽  
Advanced Breast ◽  
High Dose ◽  
Initial Management ◽  
Content Type ◽  
Fine Print

Object. Recent studies have suggested a high incidence of cognitive deficits in patients undergoing high-dose chemotherapy, which appears to be dose related. Whole-brain radiotherapy (WBRT) has previously been associated with cognitive impairment. The authors attempted to use gamma knife radiosurgery (GKS) to delay or avoid WBRT in patients with advanced breast cancer treated with high-dose chemotherapy and autologous bone marrow transplantation (HDC/ABMT) in whom brain metastases were diagnosed. Methods. A retrospective review of our experience from 1996 to 2001 was performed to identify patients who underwent HDC/ABMT for advanced breast cancer and brain metastasis. They were able to conduct GKS as initial management to avoid or delay WBRT in 12 patients following HDC/ABMT. All patients were women. The median age was 48 years (range 30–58 years). The Karnofsky Performance Scale score was 70 (range 60–90). All lesions were treated with a median prescription dose of 17 Gy (range 15–18 Gy) prescribed to the 50% isodose. Median survival was 11.5 months. Five patients (42%) had no evidence of central nervous system disease progression and no further treatment was given. Four patients were retreated with GKS and three of them eventually received WBRT as well. Two patients were treated with WBRT as the primary salvage therapy. The median time to retreatment with WBRT was 8 months after the initial GKS. Conclusions. Gamma knife radiosurgery can be effectively used for the initial management of brain metastases to avoid or delay WBRT in patients treated previously with HDC, with acceptable survival and preserved cognitive function.

Posttraumatic Anterior Hypopituitarism—Revisited: The Role of TRH Provocative Release of Prolactin in the Confirmation of Anterior Pituitary Damage

PEDIATRICS ◽  
1977 ◽  
Vol 59 (6) ◽  
pp. 948-950
Author(s):  
David R. Brown ◽  
J. Michael McMillin
Keyword(s):  
Pituitary Gland ◽  
Anterior Pituitary ◽  
Thyroid Stimulating Hormone ◽  
Anterior Pituitary Gland ◽  
Serum Prolactin ◽  
Pituitary Insufficiency ◽  
Closed Head Trauma ◽  
One Year ◽  
Stimulating Hormone

We have previously reported a case of anterior pituitary insufficiency in a 14-year-old girl following closed head trauma.1 Endocrine evaluation one year after her accident revealed hypopituitarism manifested by cachexia, hypothyroidism, hypogonadism, and hypoadrenocorticism. Laboratory studies demonstrated deficiencies of adrenocorticotropic hormone, thyroid-stimulating hormone (TSH), growth hormone, and gonadotropic hormones (follicle-stimulating hormone and luteinizing hormone). We postulated that her hypopituitarism was due to anterior pituitary gland destruction rather than stalk section or hypothalamic damage. We have recently measured her serum prolactin concentrations following provocative stimulation with thyrotropin-releasing hormone (TRH), and these results strengthen the evidence for direct anterior pituitary gland destruction and provide a more complete delineation of her endocrinologic function.

scholarly journals Fractionated Gamma Knife radiosurgery for skull base meningiomas: a single-institution experience

2019 ◽  
Vol 46 (6) ◽  
pp. E8 ◽  
Author(s):  
Krishna C. Joshi ◽  
Alankrita Raghavan ◽  
Baha’eddin Muhsen ◽  
Jason Hsieh ◽  
Hamid Borghei-Razavi ◽  
...  
Keyword(s):  
Skull Base ◽  
Gamma Knife ◽  
Tumor Volume ◽  
Gamma Knife Radiosurgery ◽  
Cranial Neuropathy ◽  
High Dose ◽  
Perilesional Edema ◽  
The Mean ◽  
Skull Base Meningiomas

OBJECTIVEGamma Knife radiosurgery (GKRS) has been successfully used for the treatment of intracranial meningiomas given its steep dose gradients and high-dose conformality. However, treatment of skull base meningiomas (SBMs) may pose significant risk to adjacent radiation-sensitive structures such as the cranial nerves. Fractionated GKRS (fGKRS) may decrease this risk, but until recently it has not been practical with traditional pin-based systems. This study reports the authors’ experience in treating SBMs with fGKRS, using a relocatable, noninvasive immobilization system.METHODSThe authors performed a retrospective review of all patients who underwent fGKRS for SBMs between 2013 and 2018 delivered using the Extend relocatable frame system or the Icon system. Patient demographics, pre- and post-GKRS tumor characteristics, perilesional edema, prior treatment details, and clinical symptoms were evaluated. Volumetric analysis of pre-GKRS, post-GKRS, and subsequent follow-up visits was performed.RESULTSTwenty-five patients met inclusion criteria. Nineteen patients were treated with the Icon system, and 6 patients were treated with the Extend system. The mean pre-fGKRS tumor volume was 7.62 cm3 (range 4.57–13.07 cm3). The median margin dose was 25 Gy delivered in 4 (8%) or 5 (92%) fractions. The median follow-up time was 12.4 months (range 4.7–17.4 months). Two patients (9%) experienced new-onset cranial neuropathy at the first follow-up. The mean postoperative tumor volume reduction was 15.9% with 6 patients (27%) experiencing improvement of cranial neuropathy at the first follow-up. Median first follow-up scans were obtained at 3.4 months (range 2.8–4.3 months). Three patients (12%) developed asymptomatic, mild perilesional edema by the first follow-up, which remained stable subsequently.CONCLUSIONSfGKRS with relocatable, noninvasive immobilization systems is well tolerated in patients with SBMs and demonstrated satisfactory tumor control as well as limited radiation toxicity. Future prospective studies with long-term follow-up and comparison to single-session GKRS or fractionated stereotactic radiotherapy are necessary to validate these findings and determine the efficacy of this approach in the management of SBMs.

scholarly journals Early versus late Gamma Knife radiosurgery following transsphenoidal resection for nonfunctioning pituitary macroadenomas: a matched cohort study

2016 ◽  
Vol 125 (1) ◽  
pp. 202-212 ◽  
Author(s):  
I. Jonathan Pomeraniec ◽  
Robert F. Dallapiazza ◽  
Zhiyuan Xu ◽  
John A. Jane ◽  
Jason P. Sheehan
Keyword(s):  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
Expectant Management ◽  
Pituitary Insufficiency ◽  
Increased Risk ◽  
Late Treatment ◽  
Early Cohort ◽  
Pituitary Macroadenomas ◽  
Transsphenoidal Resection

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.

Treatment of unresectable malignant rhabdoid tumor of the orbit with tandem high-dose chemotherapy and gamma-knife radiosurgery

2006 ◽  
Vol 47 (6) ◽  
pp. 846-850 ◽  
Author(s):  
Hiroyoshi Watanabe ◽  
Tsutomu Watanabe ◽  
Michiya Kaneko ◽  
Hiroko Suzuya ◽  
Toshihiro Onishi ◽  
...  
Keyword(s):  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
High Dose Chemotherapy ◽  
Rhabdoid Tumor ◽  
High Dose ◽  
Malignant Rhabdoid Tumor

scholarly journals Gamma Knife Radiosurgery: An Overview of Physics, Chemistry, Biology and Neuro-medicine

1970 ◽  
Vol 28 (2) ◽  
pp. 100-112
Author(s):  
KMN Uddin ◽  
JN Islam
Keyword(s):  
Gamma Knife ◽  
Vascular Malformations ◽  
Gamma Knife Radiosurgery ◽  
High Energy ◽  
Quadratic Model ◽  
High Dose ◽  
Linear Quadratic ◽  
Treatment Unit ◽  
Stereotactic Technique ◽  
Living Tissues

The gamma knife is a highly specialized treatment unit thatprovides an advanced sophisticated stereotactic approachto treatment of tumour and vascular malformations withinthe internal structure of the head. The gamma knife deliversa single high dose of radiation emanating from 201 cobalt-60 unit sources. All 201 beam simultaneously intersect atthe same time in a pre-defined location. The treatmentplanning system for gamma knife radiosurgery has beendeveloped using nonlinear programming techniques. Thesystem optimizes the shot sizes, location and weights forgamma knife treatments. Open stereotactic technique in the1990’s was essential for the treatment of a number offunctional conditions and cystic space occupying lesions.It has an important part to play in the investigation oftumours and can help to increase the number which areaccessible to treatment. It can be employed to guide notonly solid instruments but also ionizing irradiation to “masslesion– targets”. It is just this combination of stereotacticguidance and narrow beam, high energy radiation toprecisely defined target, is the basis of gamma kniferadiosurgery . The topic on radiological physics presents abroad field, which includes physics of radiation therapy,diagnosis and nuclear medicine. The emphasis is on thebasic physical principles which form a common foundationfor these areas. Consequently, the topic provides both basicradiation physics, physical aspects of treatment planningand use of radiation beams. Some knowledge of the effectof ionizing radiation on living tissues is necessary, for thosewho wish to understand the nature of any treatment usingradiation and who also wish to inform patients about suchtreatment. The topic relates to the effects of radiation onvisible structures, in other words, cells and tissues. Theradiobiological knowledge described here has beendeveloped in relation to standard radiotherapy. Moreover,the linear quadratic model of cell killing is also applicablefor single dose irradiation.DOI: 10.3329/jbcps.v28i2.5370J Bangladesh Coll Phys Surg 2010; 28: 100-112

scholarly journals The impact of cobalt-60 source age on biologically effective dose in high-dose functional Gamma Knife radiosurgery

2016 ◽  
Vol 125 (Supplement_1) ◽  
pp. 154-159 ◽  
Author(s):  
Benjamin H. Kann ◽  
James B. Yu ◽  
John M. Stahl ◽  
James E. Bond ◽  
Christopher Loiselle ◽  
...  
Keyword(s):  
Effective Dose ◽  
Dose Rate ◽  
Gamma Knife ◽  
Treatment Time ◽  
Gamma Knife Radiosurgery ◽  
High Dose ◽  
Biologically Effective Dose ◽  
Obsessive Compulsive ◽  
Compulsive Disorder ◽  
Dose Rates

OBJECTIVEFunctional Gamma Knife radiosurgery (GKRS) procedures have been increasingly used for treating patients with tremor, trigeminal neuralgia (TN), and refractory obsessive-compulsive disorder. Although its rates of toxicity are low, GKRS has been associated with some, if low, risks for serious sequelae, including hemiparesis and even death. Anecdotal reports have suggested that even with a standardized prescription dose, rates of functional GKRS toxicity increase after replacement of an old cobalt-60 source with a new source. Dose rate changes over the course of the useful lifespan of cobalt-60 are not routinely considered in the study of patients treated with functional GKRS, but these changes may be associated with significant variation in the biologically effective dose (BED) delivered to neural tissue.METHODSThe authors constructed a linear-quadratic model of BED in functional GKRS with a dose-protraction factor to correct for intrafraction DNA-damage repair and used standard single-fraction doses for trigeminal nerve ablation for TN (85 Gy), thalamotomy for tremor (130 Gy), and capsulotomy for obsessive-compulsive disorder (180 Gy). Dose rate and treatment time for functional GKRS involving 4-mm collimators were derived from calibrations in the authors' department and from the cobalt-60 decay rate. Biologically plausible values for the ratio for radiosensitivity to fraction size (α/β) and double-strand break (DSB) DNA repair halftimes (τ) were estimated from published experimental data. The biphasic characteristics of DSB repair in normal tissue were accounted for in deriving an effective τ1 halftime (fast repair) and τ2 halftime (slow repair). A sensitivity analysis was performed with a range of plausible parameter values.RESULTSAfter replacement of the cobalt-60 source, the functional GKRS dose rate rose from 1.48 to 2.99 Gy/min, treatment time fell, and estimated BED increased. Assuming the most biologically plausible parameters, source replacement resulted in an immediate relative BED increase of 11.7% for GKRS-based TN management with 85 Gy, 15.6% for thalamotomy with 130 Gy, and 18.6% for capsulotomy with 180 Gy. Over the course of the 63-month lifespan of the cobalt-60 source, BED decreased annually by 2.2% for TN management, 3.0% for thalamotomy, and 3.5% for capsulotomy.CONCLUSIONSUse of a new cobalt-60 source after replacement of an old source substantially increases the predicted BED for functional GKRS treatments for the same physical dose prescription. Source age, dose rate, and treatment time should be considered in the study of outcomes after high-dose functional GKRS treatments. Animal and clinical studies are needed to determine how this potential change in BED contributes to GKRS toxicity and whether technical adjustments should be made to reduce dose rates or prescription doses with newer cobalt-60 sources.

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