Low-dose Gamma Knife surgery for nonfunctioning pituitary adenomas

Object The primary concern when performing Gamma Knife surgery for pituitary adenoma is preservation of vision and pituitary function while achieving tumor growth control. Higher prescribed radiation doses are typically correlated with higher incidences of postradiosurgical hormone deficiencies. The goal of the present study was to retrospectively analyze the feasibility of using a lower prescribed radiation dose in the treatment of nonfunctioning pituitary adenomas and the effect of this dose on vision, pituitary function, and tumor growth control. Methods The study was conducted in 38 patients with nonfunctioning pituitary adenomas, who were treated between January 2002 and July 2008. Twenty-one patients were available for follow-up (13 men and 8 women). The mean follow-up period was 44 months (range 24–90 months). Nineteen patients had previously undergone surgery. Pituitary dysfunction developed after surgery in 3 patients. One patient had an abnormal pituitary hormone profile before radiosurgery due to an attack of pituitary apoplexy. Visual field defects were present in 12 patients. The prescribed radiation dose was 12 Gy in all patients. The tumor volume ranged from 0.5 to 11.8 cm3 (mean 4.8 cm3). The maximum dose to the visual pathway was kept below 10 Gy. The mean maximum dose delivered to the visual pathway was 7.9 Gy. Results The patients were followed up for a period of 24 to 90 months (mean 44 months). The size of the tumor decreased in 11 patients (52%) and remained stable in 9 patients (43%). In 1 patient there was tumor growth outside the previous radiation field (on the contralateral side). Among the 12 patients with visual field defects, 9 (75%) experienced an improvement and the remaining patients' vision remained stable. In only 4 patients was the visual improvement associated with tumor shrinkage. The hormone profile remained normal in all patients except for the 4 patients who had pituitary dysfunction before radiosurgery. Conclusions The 12-Gy prescribed dose used in this study seems to be sufficient for producing tumor control while sparing the patient from radiation-induced pituitary dysfunction. In addition, visual improvement was reported in a number of cases. A larger series and longer follow-up are required to confirm these results.

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Radiosurgery for Nonfunctioning Pituitary Adenomas

Neurosurgery ◽

10.1227/01.neu.0000156836.42945.28 ◽

2005 ◽

Vol 56 (4) ◽

pp. 699-705 ◽

Cited By ~ 48

Author(s):

Yoshiyasu Iwai ◽

Kazuhiro Yamanaka ◽

Katsunobu Yoshioka

Keyword(s):

Tumor Growth ◽

Pituitary Adenomas ◽

Gamma Knife Radiosurgery ◽

Growth Control ◽

Cyst Formation ◽

Morbidity Rate ◽

Nonfunctioning Pituitary Adenomas ◽

Long Term Follow Up

Abstract OBJECTIVE: We evaluated the effectiveness of gamma knife radiosurgery in the treatment of nonfunctioning pituitary adenomas. METHODS: Between January 1994 and December 1999, we treated 34 patients with nonfunctioning pituitary adenomas. Thirty-one of these patients were followed for more than 30 months. Their mean age was 52.9 years. All patients underwent resection before radiosurgery. In four patients, treatment was performed with staged radiosurgery. The treatment volume was 0.7 to 36.2 cm3 (median, 2.5 cm3). The treatment dose ranged from 8 to 20 Gy (median, 14.0 Gy) to the tumor margin. In 15 patients (48.4%), the tumor either compressed or was attached to the optic apparatus. The maximum dose to the optic apparatus was from 2 to 11 Gy (median, 8 Gy). RESULTS: Patients were followed for 30 to 108 months (median, 59.8 mo). The tumor size decreased in 18 patients (58.1%), remained unchanged in 9 patients (29.0%), and increased in four patients (12.9%). The 5-year actual tumor growth control rate was 93%. Among patients with tumor growth, two cases were secondary to cyst formation. Two patients (6.5%) required adrenal and thyroid hormonal replacement during the follow-up period after radiosurgery because of radiation-induced endocrinopathy. None of the patients sustained new cranial nerve deficits, which included optic neuropathy. CONCLUSION: In this series, radiosurgery had a high tumor growth control rate during the long-term follow-up period. Furthermore, we observed a low morbidity rate, with endocrinopathies and optic neuropathies. This low rate included even patients in whom the tumor compressed or was attached to the optic apparatus. We emphasize the necessity of long-term follow-up to evaluate late complications.

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Postsurgical Salvage Radiosurgery for Nonfunctioning Pituitary Adenomas Touching/Compressing the Optic Chiasm: Median 13-Year Postirradiation Imaging Follow-up Results

Neurosurgery ◽

10.1093/neuros/nyy357 ◽

2018 ◽

Vol 85 (4) ◽

pp. 476-485 ◽

Cited By ~ 1

Author(s):

Masaaki Yamamoto ◽

Hitoshi Aiyama ◽

Takao Koiso ◽

Shinya Watanabe ◽

Takuya Kawabe ◽

...

Keyword(s):

Tumor Growth ◽

Pituitary Adenomas ◽

Growth Control ◽

Optic Chiasm ◽

Long Term Results ◽

Nonfunctioning Pituitary Adenomas ◽

Tumor Periphery ◽

Magnetic Resonance Imaging Mri

Abstract BACKGROUND There is little information on long-term outcomes after salvage treatment by either surgery or stereotactic radiosurgery (SRS) for patients with recurrent/residual nonfunctioning pituitary adenomas (NFPAs). OBJECTIVE To reappraise the efficacy and safety of SRS for patients with NFPAs touching/compressing the optic apparatus (OA). METHODS We studied 27 patients (14 females, 13 males; mean age: 61 [range, 19-85] yr) who underwent SRS between 1998 and 2008 for NFPAs with such condition. The median tumor volume was 4.9 (range, 1.8-50.8) cc. To avoid excess irradiation to the OA, the lower part of the tumor was covered with a 50% or a 60% isodose gradient, ie 49% to 98% (mean, 84%; median, 88%) of the entire tumor received the selected doses. Median doses at the tumor periphery/OA were 7.6/11.0 (interquartile range [IQR], 5.8-9.1/10.1-11.8) Gy. RESULTS Seven patients (26%) were confirmed to be deceased due to unrelated diseases at a median post-SRS period of 149 (IQR, 83-158) mo. Follow-up magnetic resonance imaging (MRI) showed tumor growth in 2 patients (7%) at the 11th and 134th post-SRS month; the former underwent surgery and the other SRS. Excluding these 2 patients, the latest follow-up MRI examinations, performed 13 to 238 (median: 168, IQR: 120-180) mo after SRS, showed no size changes in 5 (19%) and shrinkage in 20 (74%) patients. Cumulative incidences of tumor growth control were 96.3% and 91.8% at the 120th and 180th post-SRS month. None of our patients developed subjective symptoms suggesting SRS-induced optic neuropathy or endocrinological impairment. CONCLUSION In patients with NFPAs touching/compressing the OA, SRS achieves good long-term results.

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Proliferation Index of Nonfunctioning Pituitary Adenomas: Correlations with Clinical Characteristics and Long-term Follow-up Results

Neurosurgery ◽

10.1097/00006123-200012000-00009 ◽

2000 ◽

Vol 47 (6) ◽

pp. 1313-1319 ◽

Cited By ~ 75

Author(s):

Marco Losa ◽

Alberto Franzin ◽

Francesca Mangili ◽

Maria Rosa Terreni ◽

Raffaella Barzaghi ◽

...

Keyword(s):

Pituitary Adenomas ◽

Tumor Recurrence ◽

Clinical Characteristics ◽

Ki 67 ◽

Nonfunctioning Pituitary Adenomas ◽

Age At Surgery ◽

Long Term Follow Up ◽

The Mean

ABSTRACT OBJECTIVE The recurrence of nonfunctioning pituitary adenomas (NFPAs) after surgical removal is common. The aim of our study was to investigate and correlate the growth fraction of NFPAs with clinical characteristics and long-term follow-up results. METHODS Tumor specimens were obtained from 101 consecutive patients with NFPAs (48 female patients and 53 male patients; mean age, 52.0 ± 1.5 yr). Specimens were immediately fixed in 10% buffered formalin and then embedded in paraffin. The Ki-67 antigen was assessed by immunocytochemical analysis using the monoclonal antibody MIB-1. The Ki-67 antigen labeling index (LI) was determined by counting a total of at least 1000 neoplastic nuclei. RESULTS The mean Ki-67 LI for the 101 patients was 2.4 ± 0.3% (range, 0–23.0%). Only age at surgery was inversely correlated with the Ki-67 LI; sex, maximal tumor diameter, and invasiveness into the cavernous sinuses did not significantly affect the Ki-67 LI. The mean follow-up period was 39.7 ± 2.1 months. During follow-up monitoring, 23 patients experienced tumor recurrence, after a mean period of 28.6 ± 4.8 months. Invasiveness of the tumor on preoperative magnetic resonance imaging scans was the strongest predictor of late tumor recurrence, followed by previous pituitary surgery, younger age, and lack of postoperative radiotherapy. The Ki-67 LI had no independent prognostic value. CONCLUSION Our study suggests that the clinical characteristics of patients with NFPAs, except for age at surgery, are not correlated with the Ki-67 LI. Moreover, the Ki-67 LI does not seem to provide independent information to identify patients at high risk for tumor recurrence.

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P14.104 The outcomes of conservatively observed asymptomatic nonfunctioning pituitary adenomas with optic nerve compression

Neuro-Oncology ◽

10.1093/neuonc/noz126.339 ◽

2019 ◽

Vol 21 (Supplement_3) ◽

pp. iii92-iii92

Author(s):

K Hwang ◽

Y Kim ◽

C Kim ◽

J Han

Keyword(s):

Optic Nerve ◽

Visual Field ◽

Pituitary Adenomas ◽

Surgical Intervention ◽

Tumor Resection ◽

Nerve Compression ◽

Nonfunctioning Pituitary Adenomas ◽

The Mean ◽

Optic Nerve Compression

Abstract BACKGROUND We investigated the natural history of asymptomatic nonfunctioning pituitary adenomas (NFPAs) abutting on optic nerve. MATERIAL AND METHODS Eighty-three patients with asymptomatic NFPAs with documented optic nerve compression on magnetic resonance imaging (MRI) at the time of detection between 2000 and 2016 were included in this study. Patients were evaluated with a hormone test, visual acuity test, visual field test and MRI at the time of diagnosis, and then, yearly, without any treatment (including surgery and radiation). RESULTS The mean age was 57.7±13.6 (range, 15 - 81) years. The mean follow-up duration was 66.6±39.0 (range, 12 - 184) months. Tumor volume growth ≥ 20% was observed in 64 (77.1%) patients. Ten (12.2%) patients experienced any kind of hormonal dysfunction, and gonadotropin deficiency was the most common type of hormonal deficiency [n=9 (10.8%)]. Visual deterioration quantified by Visual Impairment Scale was seen 27 (32.5%) patients. There was no statistically significant factor for tumor growth or visual aggravation. Fourteen (16.9%) patients eventually underwent tumor resection. From multivariate analysis, the significant predictors for eventual surgical intervention were cavernous sinus invasion (OR=20.95; 95% CI, 2.754–159.3; p=0.003) and last follow-up visual field defect score (OR=1.170; 95% CI, 1.049–1.305; p=0.005). All patients who underwent surgery did not experience any neurologic or endocrinological deficits postoperatively. CONCLUSION The clinical outcomes of conservatively observed NFPAs with optic nerve compression can be acceptable. The decision for surgical intervention should be made by balancing the risk and benefits.

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SURGICAL TREATMENT OF GIANT PITUITARY ADENOMAS

Neurosurgery ◽

10.1227/01.neu.0000255459.14764.ba ◽

2007 ◽

Vol 60 (6) ◽

pp. 993-1004 ◽

Cited By ~ 94

Author(s):

Pietro Mortini ◽

Raffaella Barzaghi ◽

Marco Losa ◽

Nicola Boari ◽

Massimo Giovanelli

Keyword(s):

Tumor Growth ◽

Pituitary Adenomas ◽

Protective Role ◽

Maximum Diameter ◽

Surgical Removal ◽

Consecutive Series ◽

Nonfunctioning Pituitary Adenomas ◽

Reduce Tumor Volume ◽

Giant Pituitary Adenomas ◽

The Mean

Abstract OBJECTIVE Giant pituitary adenomas, defined as those measuring at least 4 cm in maximum diameter, are a therapeutic challenge. We report our experience in a large, consecutive series of patients with giant adenomas. METHODS Between 1990 and 2004, 95 patients with a giant pituitary adenomas underwent surgery at our department. Nonfunctioning pituitary adenoma was the most frequent type (n = 70; 73.7%), whereas hormone-secreting adenomas numbered only 25 (26.3%). The mean age at the time of surgery (±standard error of the mean) was 48.4 ± 1.5 years; there were 66 men (69.5%) and 29 women (20.5%). RESULTS In total, 111 surgical procedures were performed. Of these, 85 approaches (76.6%) were transsphenoidal and 26 (23.4%) were transcranial. Visual improvement occurred in 59 of the 79 patients with preoperative defect who could be evaluated after surgery (74.7%). Radical tumor excision was obtained in 14 patients (14.7%). Adjuvant medical and radiation therapies led to 74.5% (95% confidence interval, 62.7–86.4%) control of tumor growth at 5 years. This was not different in patients with nonfunctioning pituitary adenomas compared with patients with hormone-secreting tumors. In the subgroup of patients with nonfunctioning pituitary adenomas, radiation therapy had a protective role against tumor growth (P < 0.01). CONCLUSION Maximal surgical removal of giant adenomas through the transsphenoidal or transcranial approach, or both, aimed to relieve compression of the optic pathway and reduce tumor volume as much as possible, offers the best chances to control the tumor when followed with adjuvant medical and radiation therapies.

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Gamma Knife surgery for invasive pituitary macroadenoma

Journal of Neurosurgery ◽

10.3171/sup.2006.105.7.26 ◽

2006 ◽

Vol 105 (Supplement) ◽

pp. 26-30 ◽

Cited By ~ 10

Author(s):

Mooseong Kim ◽

Sunghwa Paeng ◽

Seyoung Pyo ◽

Yeonggyun Jeong ◽

Sunil Lee ◽

...

Keyword(s):

Gamma Knife ◽

Cavernous Sinus ◽

Pituitary Adenomas ◽

Gamma Knife Surgery ◽

Tumor Control ◽

Pituitary Macroadenoma ◽

Female Ratio ◽

Fractionated Radiotherapy ◽

The Mean

ObjectPituitary adenomas have been treated using a variety of modalities including resection, medication, fractionated radiotherapy, and stereotactic radiosurgery. The policy has been that all adenomas should first be treated with resection to reduce the volume of the tumor. The authors' study was conducted to determine the efficacy of using Gamma Knife surgery (GKS) for pituitary adenomas invading the cavernous sinus.MethodsOf 397 patients with pituitary tumors who underwent GKS between October 1994 and October 2005, 68 patients had pituitary macroadenomas invading the cavernous sinus. Sixty-seven cases were available for follow up. The mean age of the patients in these cases was 42.8 years (range 14–73 years). The male/female ratio was 0.8:1. The mean adenoma volume was 9.3 cm3. A total of 24 patients had undergone craniotomies and resection, and 11 patients had undergone transsphenoidal surgery prior to GKS. The mean follow-up period was 32.8 months. Tumor control was defined as a decrease or no change in tumor volume after GKS. Endocrinological improvement was defined as a decline in hormone levels to below 50% of the pre-GKS level.Tumor control was achieved in 95.5% of the cases. Endocrinological improvement was achieved in 68% of 25 patients. One patient suffered hypopituitarism after GKS.Conclusions Gamma Knife surgery is a safe and effective treatment for invasive pituitary macroadenoma with few complications.

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Effect of Postoperative Radiotherapy on Tumor Growth of Nonfunctioning Pituitary Adenomas

Acta Endocrinologica (Bucharest) ◽

10.4183/aeb.2008.401 ◽

2008 ◽

Vol 4 (4) ◽

pp. 401-414

Author(s):

Monica Gheorghiu

Keyword(s):

Tumor Growth ◽

Pituitary Adenomas ◽

Postoperative Radiotherapy ◽

Nonfunctioning Pituitary Adenomas

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Gamma Knife surgery for Cushing's disease

Journal of Neurosurgery ◽

10.3171/jns.2007.106.6.980 ◽

2007 ◽

Vol 106 (6) ◽

pp. 980-987 ◽

Cited By ~ 192

Author(s):

Jay Jagannathan ◽

Jason P. Sheehan ◽

Nader Pouratian ◽

Edward R. Laws ◽

Ladislau Steiner ◽

...

Keyword(s):

Gamma Knife ◽

Cushing’S Disease ◽

Pituitary Adenomas ◽

Cranial Nerve ◽

Gamma Knife Surgery ◽

Cushing's Disease ◽

Free Cortisol ◽

Radiation Induced ◽

The Mean

Object In this study the authors address the efficacy and safety of Gamma Knife surgery (GKS) in patients with adrenocorticotropic hormone–secreting pituitary adenomas. Methods A review of data collected from a prospective GKS database between January 1990 and March 2005 was performed in patients with Cushing's disease. All but one patient underwent resection for a pituitary tumor, without achieving remission. Successful endocrine outcome after GKS was defined as a normal 24-hour urinary free cortisol (UFC) concentration posttreatment after a minimum of 1 year of follow up. Patient records were also evaluated for changes in tumor volume, development of new hormone deficiencies, visual acuity, cranial nerve neuropathies, and radiation-induced imaging changes. Ninety evaluable patients had undergone GKS, with a mean endocrine follow-up duration of 45 months (range 12–132 months). The mean dose to the tumor margin was 23 Gy (median 25 Gy). Normal 24-hour UFC levels were achieved in 49 patients (54%), with an average time of 13 months after treatment (range 2–67 months). In the 49 patients in whom a tumor was visible on the planning magnetic resonance (MR) image, a decrease in tumor size occurred in 39 (80%), in seven patients there was no change in size, and tumor growth occurred in three patients. Ten patients (20%) experienced a relapse of Cushing's disease after initial remission; the mean time to recurrence was 27 months (range 6–60 months). Seven of these patients underwent repeated GKS, with three patients achieving a second remission. New hormone deficiencies developed in 20 patients (22%), with hypothyroidism being the most common endocrinopathy after GKS. Five patients experienced new visual deficits or third, fourth, or sixth cranial nerve deficits; two of these patients had undergone prior conventional fractionated radiation therapy, and four of them had received previous GKS. Radiation-induced changes were observed on MR images in three patients; one had symptoms attributable to these changes. Conclusions Gamma Knife surgery is an effective treatment for persistent Cushing's disease. Adenomas with cavernous sinus invasion that are not amenable to resection are treatable with the Gamma Knife. A second GKS treatment appears to increase the risk of cranial nerve damage. These results demonstrate the value of combining two neurosurgical treatment modalities—microsurgical resection and GKS—in the management of pituitary adenomas.

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Gamma Knife Radiosurgery for the Treatment of Cavernous Sinus Meningiomas

Neurosurgery ◽

10.1227/01.neu.0000047814.18819.9f ◽

2003 ◽

Vol 52 (3) ◽

pp. 517-524 ◽

Cited By ~ 111

Author(s):

Yoshiyasu Iwai ◽

Kazuhiro Yamanaka ◽

Tomoya Ishiguro

Keyword(s):

Tumor Growth ◽

Gamma Knife ◽

Cavernous Sinus ◽

Tumor Regression ◽

Gamma Knife Radiosurgery ◽

Growth Control ◽

Neurological Deficits ◽

Surgical Removal ◽

Tumor Diameter

Abstract OBJECTIVE We report on the efficacy of gamma knife radiosurgery for cavernous sinus meningiomas. METHODS Between January 1994 and December 1999, we used gamma knife radiosurgery for the treatment of 43 patients with cavernous sinus meningiomas. Forty-two patients were followed up for a mean of 49.4 months (range, 18–84 mo). The patients' average age was 55 years (range, 18–81 yr). Twenty-two patients (52%) underwent operations before radiosurgery, and 20 patients (48%) underwent radiosurgery after the diagnosis was made by magnetic resonance imaging. The tumor volumes ranged from 1.2 to 101.5 cm3 (mean, 14.7 cm3). The tumors either compressed or were attached to the optic apparatus in 17 patients (40.5%). The marginal radiation dose was 8 to 15 Gy (mean, 11 Gy), and the optic apparatus was irradiated with 2 to 12 Gy (mean, 6.2 Gy). Three patients with a mean tumor diameter greater than 4 cm were treated by two-stage radiosurgery. RESULTS Thirty-eight patients (90.5%) demonstrated tumor growth control during the follow-up period after radiosurgery. Tumor regression was observed in 25 patients (59.5%), and growth was unchanged in 13 patients (31%). Regrowth or recurrence occurred in four patients (9.5%). The actual tumor growth control rate at 5 years was 92%. Only one patient (2.4%) experienced regrowth within the treatment field; in other patients, regrowth occurred at sites peripheral to or outside the treatment field. Twelve patients (28.6%) had improved clinically by the time of the follow-up examination. None of the patients experienced optic neuropathy caused by radiation injury or any new neurological deficits after radiosurgery. CONCLUSION Gamma knife radiosurgery may be a useful option for the treatment of cavernous sinus meningiomas not only as an adjuvant to surgery but also as an alternative to surgical removal. We have shown it to be safe and effective even in tumors that adhere to or are in close proximity to the optic apparatus.

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