USE OF TEMOZOLOMIDE IN AGGRESSIVE PITUITARY TUMORS

Abstract OBJECTIVE The management of aggressive pituitary macroadenomas represents a challenge to neurosurgeons. These tumors are very difficult to treat, owing mainly to their invasive nature, thus resulting in incomplete resections and propensity for recurrence. Multiple surgical procedures (transsphenoidal, transcranial, or a combination of both) are the first line management, followed by radiotherapy and chemotherapy. CLINICAL PRESENTATION Three cases of patients with pituitary adenomas who underwent temozolomide treatment are presented. The first 2 patients had corticotroph macroadenoma of the Crooke's cell variant. Deterioration occurred in both cases despite multiple surgeries and adjuvant therapy. The third patient had a glioblastoma multiforme with an incidental pituitary tumor. INTERVENTION All 3 patients had temozolomide administered orally on the first 5 days of a 28-day cycle for 12 cycles. Magnetic resonance imaging, endocrinological, and clinical follow-up were performed at monthly intervals. CONCLUSION The marked improvement in clinical state of the first 2 patients accompanied by radiological evidence of tumor shrinkage in all patients demonstrates the potential use of temozolomide in treating aggressive pituitary macroadenomas. The usefulness of temozolomide in aggressive pituitary adenomas should be studied in larger trials.

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Variability and Lack of Prognostic Value Associated With Atypical Pituitary Adenoma Diagnosis: A Systematic Review and Critical Assessment of the Diagnostic Criteria

Neurosurgery ◽

10.1093/neuros/nyx541 ◽

2017 ◽

Vol 83 (4) ◽

pp. 602-610 ◽

Cited By ~ 2

Author(s):

Kelsi Chesney ◽

Zoe Memel ◽

Dhiraj J Pangal ◽

Daniel Donoho ◽

Kyle Hurth ◽

...

Keyword(s):

Systematic Review ◽

Pituitary Adenomas ◽

Pituitary Tumors ◽

World Health ◽

Resonance Imaging ◽

Prognostic Utility ◽

Atypical Pituitary Adenoma ◽

Health Organization

Abstract BACKGROUND Atypical pituitary adenomas (APAs) are a subset of pituitary adenomas (PAs) characterized by the 2004 World Health Organization (WHO) guidelines to have higher risk histopathological features than typical PAs. In July 2017, the WHO published an update to their classification of pituitary tumors and abandoned the APA terminology. OBJECTIVE To assess the prevalence and outcomes of patients diagnosed with APA through a literature review. Focus was placed on variation in the application of the previous WHO criteria and on rates of recurrence. METHODS A systematic review of PubMed (2004-July 2017) was performed to identify studies reporting prevalence and clinical characteristics/outcomes of APA. Eight studies were analyzed for prevalence. Six studies reporting histopathological details were analyzed in depth. RESULTS Of the 7105 included patients, 373 (5.2%) met criteria for APA (prevalence range: 3%-15%). Only 2 of 8 studies utilized identical grading criteria, demonstrating a lack of standardized application. Most APAs (84%) were macroadenomas, with 52% invasive on magnetic resonance imaging. Nonfunctional PAs were most common (37%), followed by prolactinomas (23%) and Growth Hormone adenomas (21%). Recurrence/progression occurred in 21% of APA patients (follow-up range 37-75 mo). Only 2 of 8 studies reported an association between APA diagnosis and recurrence/progression. CONCLUSION Based on diagnostic variability and lack of association with clinical outcomes, refinement of criteria for APA was necessary. The WHO update eliminates the ambiguity in APA diagnosis in favor of criteria that emphasize clinical behavior (invasion, recurrence, and resistance to treatment) and molecular markers. Our review supports abandonment of the previous APA designation due to limited prognostic utility.

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Aggressive Intramedullary Melanotic Schwannoma: Case Report

Neurosurgery ◽

10.1227/01.neu.0000143617.25417.68 ◽

2004 ◽

Vol 55 (6) ◽

pp. E1430-E1434 ◽

Cited By ~ 24

Author(s):

Carlo Santaguida ◽

Abdulrahman J. Sabbagh ◽

Marie-Christine Guiot ◽

Rolando F. Del Maestro

Keyword(s):

Clinical Presentation ◽

Magnetic Resonance Imaging Scan ◽

Resonance Imaging ◽

Total Resection ◽

Neck Stiffness ◽

Neck Extension ◽

Melanotic Schwannoma ◽

Pathological Characteristics ◽

Intramedullary Lesion

Abstract OBJECTIVE AND IMPORTANCE: Intramedullary melanotic schwannomas are very rare lesions; only four cases have been reported previously. We describe a patient with an intramedullary melanotic schwannoma that had a more aggressive course than those reported in the literature, and we review the theories regarding the cause of these lesions. CLINICAL PRESENTATION: A 35-year-old man presented with neck stiffness and paraesthesia extending down his right arm upon neck extension. A magnetic resonance imaging scan revealed an intramedullary lesion extending from C4 to C5. INTERVENTION: Gross total resection of the mass was performed, and pathological characteristics were consistent with a melanotic schwannoma. Two years after resection the tumor recurred, and the patient was treated with radiation therapy. The tumor progressed 2 years after radiotherapy, and at repeat resection, multiple pigmented foci were present on the surface of the spinal cord and dura consistent with metastatic seeding. CONCLUSION: In a patient with intramedullary melanotic schwannoma with an unusually aggressive course, careful follow-up may be essential.

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Endoscopic endonasal transsphenoidal approach for pituitary adenomas: technical aspects and report of casuistic

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2010000400024 ◽

2010 ◽

Vol 68 (4) ◽

pp. 608-612 ◽

Cited By ~ 16

Author(s):

Américo Rubens Leite dos Santos ◽

Roberto Monteiro Fonseca Neto ◽

José Carlos Esteves Veiga ◽

José Viana Jr ◽

Nilza Maria Scaliassi ◽

...

Keyword(s):

Pituitary Adenomas ◽

Pituitary Tumors ◽

Hormonal Control ◽

Subtotal Resection ◽

Endoscopic Endonasal ◽

Technical Aspects ◽

Transphenoidal Approach ◽

Acth Secreting ◽

Csf Leaks

OBJECTIVE: Analyse technical aspects, effectiveness and morbidity of the endoscopic endonasal transphenoidal approach for pituitary adenomas. METHOD: From January 2005 to September 2008, 30 consecutive patients underwent endoscopic endonasal resection of pituitary adenomas with a follow up from 3 to 36 months. Their medical charts were retrospectively analysed. RESULTS: There were 18 women and 12 men, mean age 44 years (range 17-65 yr). Among the 30 patients, 23 had macroadenomas and 7 microadenomas. Twelve patients had non-functioning tumors, 9 had ACTH-secreting tumors, 8 had GH-secreting tumors and 1 prolactinoma. Complete resection and hormonal control was achieved in all microadenomas. Macroadenomas were completely removed in 6 patients, subtotal resection in 6 and partial resection in 11. Three patients had diabetes insipidus and 5 had CSF leaks treated with lumbar drainage. CONCLUSION: The endonasal endoscopic approach for pituitary tumors is effective and has low morbidity.

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The changing spectrum of TSH-secreting pituitary adenomas: diagnosis and management in 43 patients

Acta Endocrinologica ◽

10.1530/eje.0.1480433 ◽

2003 ◽

Vol 148 (4) ◽

pp. 433-442 ◽

Cited By ~ 169

Author(s):

HV Socin ◽

P Chanson ◽

B Delemer ◽

A Tabarin ◽

V Rohmer ◽

...

Keyword(s):

Pituitary Adenomas ◽

Somatostatin Analogs ◽

Pituitary Tumors ◽

Positron Emission Tomography Scan ◽

First Line ◽

Chi Square ◽

Diagnosis And Management ◽

Positron Emission ◽

Tomography Scan

OBJECTIVE: Our aim was to report the recent changes in diagnosis and management of TSH-secreting pituitary adenomas. METHODS: We retrieved 43 consecutive patients with TSH-secreting pituitary tumors (23 male and 20 female) among 4400 pituitary adenomas followed between 1976 and 2001 in six Belgian and French centers. RESULTS: TSH was elevated in 18/43 and alpha subunit in 13/32 patients. In patients with intact thyroid (n=30), mean free tri-iodothyronine was 13.1 pmol/l (range 3.5-23) and mean free thyroxine was 38.4 pmol/l (range 10.2-62.7). Hyperprolactinemia and acromegaly were associated in 9/43 and 8/43 cases. The number of associated hypersecretions was higher in macroadenomas than in microadenomas (Chi square = 11.2, P<0.01). Two women had sporadic multiple endocrine neoplasia type 1-associated syndrome. The proportion of microadenomas versus macroadenomas was 1/11 (period 1974-1986) and 8/32 (period 1987-2001). Bilateral petrosal sinus sampling, (111)In-pentreotide scintigraphy and ((11)C)-l-methionine positron emission tomography scan confirmed diagnosis in four questionable microadenomas. Macroadenomas with extrasellar extension (31 cases) had a tendency to be medially located. Medical treatment with somatostatin analogs was initiated as first-line treatment in 26 patients. TSH levels were reduced by more than 50% in 23/26 cases. A tumoral shrinkage of more than 20% was observed in 5/13 cases. Surgery was performed in 36 patients. After 1 year, 21 of them (58.3%) met the criteria of surgical favorable outcome. Pituitary radiotherapy (n=8) and somatostatin analogs allowed normalization in cases not cured by surgery. CONCLUSION: Ultrasensitive methods for TSH measurement led to an earlier recognition of TSH-secreting pituitary tumors. In this series, we observed that TSH-secreting pituitary tumors are today more frequently found at the stage of microadenomas, medially located, without associated hypersecretions and needing new exploration methods as compared with older series. This changing spectrum in the presentation of TSH-secreting pituitary tumors and the excellent response to somatostatin analogs has been accompanied by an improvement in the prognosis of the disease.

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A STUDY OF CLINICAL PRESENTATION AND MANAGEMENT OF PITUITARY TUMORS

10.36106/7630963 ◽

2021 ◽

pp. 58-60

Author(s):

Manthan Patel ◽

Naimish Patel

Keyword(s):

Clinical Presentation ◽

Clinical Symptoms ◽

Pituitary Tumors ◽

Csf Leak ◽

Total Removal ◽

Diagnostic Investigation ◽

Subtotal Removal ◽

Visual Disturbances ◽

Bitemporal Hemianopia

The study includes 25 cases of pituitary adenomas. Most common age group by pituitary tumors falls between 41-50 years of age. Male: Female incidence of these tumors is 1: 2.12. Most common clinical symptoms in our series are visual disturbances followed by headache. Optic nerve involvement is other common clinical nding presenting in form of decreased vision or loss of vision, eld defect or fundus changes. Commonest eld defect is bitemporal hemianopia. MRI is the diagnostic investigation of choice in pituitary tumors to dene extent, invasion and relationship to major vessels and nerves. Approximately half (44%) of the patients exhibited normal preoperative pituitary function in form of baseline hormone prole. Increased GH level (32%) followed by hyperprolactinemia (20%) are the most common endocrinologic abnormalities. Total/near total removal was done in 21 patients (84%) and subtotal removal done in 4 patients (16%). Adjuvant therapies were given in 5 patients. Two patients were given radiotherapy and 3 were given pharmacotherapy. Post operative complications were CSF leak, diabetes insipidus and meningitis. 20 patients (80%) had improvement in their symptoms including relief from headache, improvement in vision and endocrinal dysfunction. Post operatively visual functions improved in 13 patients (52%) and it remained stationary in 11 (44%) patients. Only one patient (4%) complained of worsening of his visual function and it was improved in follow up period

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Balanitis Xerotica Obliterans

Urologia Journal ◽

10.1177/039156030707400403 ◽

2007 ◽

Vol 74 (4) ◽

pp. 206-211

Author(s):

C. Calcagno

Keyword(s):

Squamous Cell Carcinoma ◽

Clinical Presentation ◽

Local Therapy ◽

Line Treatment ◽

First Line ◽

Balanitis Xerotica Obliterans ◽

Malignant Lesions ◽

The Relationship ◽

First Line Treatment

Balanitis xerotica obliterans (BXO), first described by Stuhmer in 1928, is a chronic, progressive, atrophic, sclerosing process involving prepuce, glans and urethra. Its aetiology is unknown. After a short terminological excursus and a review of the aetiological hypothesis, we have focused on BXO in daily urological practice. We are here describing the clinical presentation and its differential diagnosis with premalignant and malignant lesions of the penis. We tried to define the relationship between BXO and squamous cell carcinoma of the penis. Particular attention was then cast on urethral stenosis. Finally, we focused on the treatment of BXO: corticosteroid local therapy as first line treatment or as adjuvant therapy after circumcision, surgical therapy including circumcision, laser therapy of the glans lesions, meatoplasty in the stenosis of the anterior urethra. We also stressed the need for histological examination of the preputial specimen for a correct follow-up and for medicolegal reasons.

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INTRADURAL CLIVAL CHORDOMA AND ECCHORDOSIS PHYSALIPHORA

Neurosurgery ◽

10.1227/01.neu.0000337064.57270.f0 ◽

2009 ◽

Vol 64 (2) ◽

pp. E387-E388 ◽

Cited By ~ 34

Author(s):

Riccardo Ciarpaglini ◽

Ernesto Pasquini ◽

Diego Mazzatenta ◽

Andrea Ambrosini-Spaltro ◽

Vittorio Sciarretta ◽

...

Keyword(s):

Clinical Presentation ◽

Memory Loss ◽

Histological Findings ◽

Postoperative Radiation ◽

Resonance Imaging ◽

Postoperative Radiation Therapy ◽

Ecchordosis Physaliphora ◽

Subtotal Removal ◽

With Memory

Abstract OBJECTIVE Purely intradural clival chordomas are rare neoplasms, and only a few cases have been reported. The reported cases present features similar to ecchordosis physaliphora, which is a notochordal remnant. We describe these 2 entities and their differential diagnoses, clinical courses, and management. This is the first reported case to be treated using a neuroendoscopic technique. CLINICAL PRESENTATION A 60-year-old man presenting with memory loss underwent magnetic resonance imaging, which revealed an intradural retroclival mass without bone involvement. INTERVENTION The patient underwent an endoscopic transsphenoidal-transclival procedure with subtotal removal of the tumor. Histological findings confirmed the diagnosis of a chordoma. CONCLUSION Even if some parameters exist for a differential diagnosis, ecchordosis physaliphora and intradural chordoma may represent different aspects of the spectrum of the same pathology. Intradural clival chordomas have a better prognosis with respect to classic chordomas. Therefore, in subtotal removal such as that performed in our case, postoperative radiation therapy should be performed only if a regrowth of the remnant is seen during neuroradiological follow-up.

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Spontaneous Resolution of Hemorrhagic Pseudocyst-Associated Pseudoaneurysm in Groove Pancreatitis

Case Reports in Gastroenterology ◽

10.1159/000502836 ◽

2020 ◽

Vol 14 (1) ◽

pp. 131-136

Author(s):

Gwang Mo Kim ◽

Soon Young Ko ◽

Joon Ho Wang

Keyword(s):

Pancreatic Duct ◽

Clinical Presentation ◽

Healing Process ◽

Stable Condition ◽

Pancreatic Head ◽

Stent Insertion ◽

First Line ◽

Groove Pancreatitis ◽

Pancreatic Sphincterotomy

Hemorrhagic pseudocyst (HP) and pseudocyst-associated pseudoaneurysms (PPs) are complications of pseudocyst. Angiography with embolization has been advocated as the first-line intervention for HP. A 47-year-old man with groove pancreatitis combined with HP near the pancreatic head was treated conservatively. He had relapsed pancreatitis with a newly identified pseudoaneurysm; however, the pseudocyst size was reduced. Although pseudoaneurysm was identified, angiography was not performed because there was no evidence of ongoing bleeding, and he was in a stable condition. Sphincterotomy and stent insertion in the pancreatic duct was applied to prevent relapsed pancreatitis with facilitation of the flow of pancreatic juice. He has done well during the 10-month follow-up, without recurrent pancreatitis. Angiography as an initial approach in HP and PPs may need to be more selective depending on the clinical presentation of the patient. A lysed clot within the strictured pancreatic duct during the healing process has been thought to be the cause of relapsed pancreatitis, and pancreatic sphincterotomy and stent insertion should be the preferred treatment methods.

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JUVENILE INTRADURAL CHORDOMA

Neurosurgery ◽

10.1227/01.neu.0000316022.74162.00 ◽

2008 ◽

Vol 62 (2) ◽

pp. E525-E527 ◽

Cited By ~ 20

Author(s):

Steven W. Chang ◽

Pankaj A. Gore ◽

Peter Nakaji ◽

Harold L. Rekate

Keyword(s):

Clinical Presentation ◽

Radiation Treatment ◽

Complete Resection ◽

Magnetic Resonance Imaging Scan ◽

Resonance Imaging ◽

Total Resection ◽

Surgical Cure ◽

Neurologically Intact ◽

Resonance Imaging Scan

Abstract OBJECTIVE We report the youngest known case of a prepontine intradural chordoma. These tumors are exceedingly rare. Unlike their more common extradural counterparts, no recurrence of an intradural chordoma has been reported. CLINICAL PRESENTATION A 9-year-old boy underwent diagnostic imaging for evaluation of headaches. Although neurologically intact, a magnetic resonance imaging scan revealed a large prepontine mass with focal enhancement. INTERVENTION Endoscopic-assisted gross total resection was attained with staged bilateral retrosigmoid approaches. There were no additional adjuvant therapies. At the time of the 1-year follow-up evaluation, the patient had no recurrence. CONCLUSION By using an endoscopic-assisted procedure, we achieved complete resection of an intradural chordoma offering a potential for surgical cure. Resection is particularly advantageous because it spares the young child the need for radiation treatment. Close follow-up is warranted because we postulate that this tumor exists in a biological continuum between benign notochordal hamartomatous remnants and typical invasive chordomas.

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HYPOFRACTIONATED CYBERKNIFE RADIOSURGERY FOR PERICHIASMATIC PITUITARY ADENOMAS

Neurosurgery ◽

10.1227/01.neu.0000341630.42160.18 ◽

2009 ◽

Vol 64 (suppl_2) ◽

pp. A19-A25 ◽

Cited By ~ 46

Author(s):

Brendan D. Killory ◽

John J. Kresl ◽

Scott D. Wait ◽

Francisco A. Ponce ◽

Randall Porter ◽

...

Keyword(s):

Optic Nerve ◽

Pituitary Adenomas ◽

Pituitary Tumors ◽

Field Testing ◽

Optic Chiasm ◽

Conformity Index ◽

Tumor Control ◽

Cyberknife Radiosurgery ◽

The Mean

Abstract OBJECTIVE Radiation therapy is recommended for pituitary tumors that are refractory to surgical and medical therapies. The efficacy of single-fraction radiosurgery is established for these lesions, but lesions within 3 mm of the optic pathway cannot be safely treated with doses higher than 8 to 10 Gy. We hypothesized that the optic nerve will tolerate 5 consecutive daily radiosurgery fractions of 500 cGy with effective tumor control. METHODS We reviewed our first 20 patients with recurrent or residual pituitary adenomas within 3 mm of the optic chiasm treated with the CyberKnife radiosurgery system (Accuray, Inc., Sunnyvale, CA). Tumors were treated with a mean coverage of 97 ± 2.2% (range, 89.8–99.7%), a mean conformity index of 1.3 ± 0.2 (range, 1.1–1.6), and a mean treatment isodose line of 74.5 ± 6.6% (range, 60–86%). The primary end point was an interim analysis of visual preservation, and secondary end points were radiographic and endocrinological tumor control. RESULTS The mean follow-up period for visual field testing was 26.6 ± 10.5 months (range, 10.6–41 months). The vision of all 14 patients with intact preoperative vision remained intact. Of the 5 patients with impaired vision, 2 remained stable, and 3 improved. No patient's vision deteriorated. The mean radiographic follow-up was 29.3 ± 8.6 months (range, 10.2–40.5 months). On magnetic resonance imaging, 12 tumors were stable, 8 were smaller, and none enlarged. CONCLUSION This preliminary study establishes that the optic nerve and chiasm tolerate CyberKnife hypofractionated radiosurgery of 5 × 500 cGy to perichiasmatic pituitary adenomas. Early data suggest that this dosing paradigm may achieve satisfactory radiographic and endocrinological tumor control for these challenging lesions, but longer follow-up is necessary to confirm these results.

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