Hypopituitarism after Gamma Knife radiosurgery for pituitary adenomas: a multicenter, international study

OBJECTIVERecurrent or residual adenomas are frequently treated with Gamma Knife radiosurgery (GKRS). The most common complication after GKRS for pituitary adenomas is hypopituitarism. In the current study, the authors detail the timing and types of hypopituitarism in a multicenter, international cohort of pituitary adenoma patients treated with GKRS.METHODSSeventeen institutions pooled clinical data obtained from pituitary adenoma patients who were treated with GKRS from 1988 to 2016. Patients who had undergone prior radiotherapy were excluded. A total of 1023 patients met the study inclusion criteria. The treated lesions included 410 nonfunctioning pituitary adenomas (NFPAs), 262 cases of Cushing’s disease (CD), and 251 cases of acromegaly. The median follow-up was 51 months (range 6–246 months). Statistical analysis was performed using a Cox proportional hazards model to evaluate factors associated with the development of new-onset hypopituitarism.RESULTSAt last follow-up, 248 patients had developed new pituitary hormone deficiency (86 with NFPA, 66 with CD, and 96 with acromegaly). Among these patients, 150 (60.5%) had single and 98 (39.5%) had multiple hormone deficiencies. New hormonal changes included 82 cortisol (21.6%), 135 thyrotropin (35.6%), 92 gonadotropin (24.3%), 59 growth hormone (15.6%), and 11 vasopressin (2.9%) deficiencies. The actuarial 1-year, 3-year, 5-year, 7-year, and 10-year rates of hypopituitarism were 7.8%, 16.2%, 22.4%, 27.5%, and 31.3%, respectively. The median time to hypopituitarism onset was 39 months.In univariate analyses, an increased rate of new-onset hypopituitarism was significantly associated with a lower isodose line (p = 0.006, HR = 8.695), whole sellar targeting (p = 0.033, HR = 1.452), and treatment of a functional pituitary adenoma as compared with an NFPA (p = 0.008, HR = 1.510). In multivariate analyses, only a lower isodose line was found to be an independent predictor of new-onset hypopituitarism (p = 0.001, HR = 1.38).CONCLUSIONSHypopituitarism remains the most common unintended effect of GKRS for a pituitary adenoma. Treating the target volume at an isodose line of 50% or greater and avoiding whole-sellar radiosurgery, unless necessary, will likely mitigate the risk of post-GKRS hypopituitarism. Follow-up of these patients is required to detect and treat latent endocrinopathies.

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Gamma Knife surgery for pituitary adenomas: factors related to radiological and endocrine outcomes

Journal of Neurosurgery ◽

10.3171/2010.5.jns091635 ◽

2011 ◽

Vol 114 (2) ◽

pp. 303-309 ◽

Cited By ~ 114

Author(s):

Jason P. Sheehan ◽

Nader Pouratian ◽

Ladislau Steiner ◽

Edward R. Laws ◽

Mary Lee Vance

Keyword(s):

Pituitary Adenoma ◽

Radiation Dose ◽

Tumor Growth ◽

Gamma Knife ◽

Pituitary Adenomas ◽

Gamma Knife Surgery ◽

Hormone Deficiency ◽

Pituitary Hormone ◽

Pituitary Hormone Deficiency

Object Gamma Knife surgery (GKS) is a common treatment for recurrent or residual pituitary adenomas. This study evaluates a large cohort of patients with a pituitary adenoma to characterize factors related to endocrine remission, control of tumor growth, and development of pituitary deficiency. Methods A total of 418 patients who underwent GKS with a minimum follow-up of 6 months (median 31 months) and for whom there was complete follow-up were evaluated. Statistical analysis was performed to evaluate for significant factors (p < 0.05) related to treatment outcomes. Results In patients with a secretory pituitary adenoma, the median time to endocrine remission was 48.9 months. The tumor margin radiation dose was inversely correlated with time to endocrine remission. Smaller adenoma volume correlated with improved endocrine remission in those with secretory adenomas. Cessation of pituitary suppressive medications at the time of GKS had a trend toward statistical significance in regard to influencing endocrine remission. In 90.3% of patients there was tumor control. A higher margin radiation dose significantly affected control of adenoma growth. New onset of a pituitary hormone deficiency following GKS was seen in 24.4% of patients. Treatment with pituitary hormone suppressive medication at the time of GKS, a prior craniotomy, and larger adenoma volume at the time of radiosurgery were significantly related to loss of pituitary function. Conclusions Smaller adenoma volume improves the probability of endocrine remission and lowers the risk of new pituitary hormone deficiency with GKS. A higher margin dose offers a greater chance of endocrine remission and control of tumor growth.

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Long-term Outcomes After Gamma Knife Radiosurgery for Patients With a Nonfunctioning Pituitary Adenoma

Neurosurgery ◽

10.1227/neu.0b013e31821bc44e ◽

2011 ◽

Vol 69 (2) ◽

pp. 284-293 ◽

Cited By ~ 73

Author(s):

Rupa Gopalan ◽

David Schlesinger ◽

Mary Lee Vance ◽

Edward Laws ◽

Jason Sheehan

Keyword(s):

Pituitary Adenoma ◽

Diabetes Insipidus ◽

Pituitary Adenomas ◽

Tumor Volume ◽

Gamma Knife Radiosurgery ◽

Hormone Deficiency ◽

Tumor Control ◽

Nonfunctioning Pituitary Adenoma

Abstract BACKGROUND: Nonfunctioning pituitary adenomas recur after microsurgery. Gamma Knife radiosurgery (GKRS) has been used to treat recurrent adenomas. OBJECTIVE: To evaluate the long-term rates of tumor control and development of hypopituitarism in patients with nonfunctioning pituitary adenomas after GKRS. METHODS: Forty-eight patients with a nonfunctioning pituitary adenoma treated between 1991 and 2004 at the University of Virginia were studied. All patients had more than 4 years of clinical and imaging follow-up. RESULTS: All patients underwent follow-up imaging and endocrine evaluations, with a duration ranging from 50 to 215 months (median, 80.5 months) and 57 to 201 months (median, 95 months), respectively. New hormone deficiency after GKRS occurred in 19 of 48 patients (39%). Corticotropin/cortisol deficiency developed in 8% of patients, thyroid hormone deficiency in 20.8%, gonadotropin deficiency in 4.2%, growth hormone/insulin-like growth factor 1 in 16.7%, and diabetes insipidus in 2%. Panhypopituitarism including diabetes insipidus developed in 1 patient. Overall, control of tumor volume was 83%. Tumor volume decreased in 36 patients (75%), increased in 8 patients (17%), and was unchanged in 4 patients (8%). Tumor volumes greater than 5 mL at the time of GKRS were associated with a significantly greater rate of growth (P = .003) compared with an adenoma with a volume of 5 mL or less. CONCLUSION: GKRS resulted in a high and durable rate of tumor control in patients with a nonfunctioning pituitary adenoma. A higher preoperative tumor volume was associated with an increased rate of tumor growth.

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Gamma Knife in the Treatment of Pituitary Adenomas: Results of a Single Center

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100014645 ◽

2013 ◽

Vol 40 (4) ◽

pp. 546-552 ◽

Cited By ~ 11

Author(s):

F. A. Zeiler ◽

M. Bigder ◽

A. Kaufmann ◽

P. J. McDonald ◽

D. Fewer ◽

...

Keyword(s):

Tumor Growth ◽

Gamma Knife ◽

Pituitary Adenomas ◽

Gamma Knife Radiosurgery ◽

Tumor Diameter ◽

Average Dose ◽

Complication Rates ◽

Average Maximum ◽

Lost To Follow Up

Abstract:Introduction:Gamma Knife (GK) radiosurgery for pituitary adenomas can offer a means of tumor and biologic control with acceptable risk and low complication rates.Methods:Retrospective review of all the patients treated at our center with GK for pituitary adenomas from Nov 2003 to June 2011.Results:We treated a total of 86 patients. Ten were lost to follow-up. Mean follow was 32.8 months. There were 21 (24.4%) growth hormone secreting adenomas (GH), 8 (9.3%) prolactinomas (PRL), 8 (9.3%) adrenocorticotropic hormone secreting (ACTH) adenomas, 2 (2.3%) follicle stimulating hormone/luteinizing hormone secreting (FSH/LH) adenomas, and 47 (54.7%) null cell pituitary adenomas that were treated. Average maximum tumor diameter and volume was 2.21cm and 5.41cm3, respectively. The average dose to the 50% isodose line was 14.2 Gy and 23.6 Gy for secreting and non-secreting adenomas respectively. Mean maximal optic nerve dose was 8.87 Gy. Local control rate was 75 of 76 (98.7%), for those with followup. Thirty-three (43.4%) patients experienced arrest of tumor growth, while 42 (55.2%) patients experienced tumor regression. Of the 39 patients with secreting pituitary tumors, 6 were lost to follow-up. Improved endocrine status occurred in 16 (50.0%), while 14 (43.8%) demonstrated stability of hormone status on continued pre-operative medical management. Permanent complications included: panhypopituitarism (4), hypothyroidism (4), hypocortisolemia (1), diabetes insipidus (1), apoplexy (1), visual field defect (2), and diplopia (1).Conclusions:Gamma Knife radiosurgery is a safe and effective means of achieving tumor growth control and endocrine remission/stability in pituitary adenomas.

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Gamma Knife radiosurgery for vestibular schwannomas: evaluation of tumor control and its predictors in a large patient cohort in The Netherlands

Journal of Neurosurgery ◽

10.3171/2015.4.jns142415 ◽

2016 ◽

Vol 124 (6) ◽

pp. 1619-1626 ◽

Cited By ~ 41

Author(s):

Stijn Klijn ◽

Jeroen B. Verheul ◽

Guus N. Beute ◽

Sieger Leenstra ◽

Jef J. S. Mulder ◽

...

Keyword(s):

Gamma Knife ◽

Tumor Volume ◽

Gamma Knife Radiosurgery ◽

Hearing Preservation ◽

Cox Proportional Hazards Model ◽

Tumor Control ◽

Complication Rates ◽

Tumor Control Rate ◽

Large Patient

OBJECT The authors of this study sought to assess tumor control and complication rates in a large cohort of patients who underwent Gamma Knife radiosurgery (GKRS) for vestibular schwannoma (VS) and to identify predictors of tumor control. METHODS The records of 420 patients treated with GKRS for VS with a median marginal dose of 11 Gy were retrospectively analyzed. Patients with neurofibromatosis Type 2 or who had undergone treatment for VS previously were excluded. The authors assessed tumor control and complication rates with chart review and used the Cox proportional hazards model to identify predictors of tumor control. Preservation of serviceable hearing, defined as Gardner-Robertson Class I–II, was evaluated in a subgroup of 71 patients with serviceable hearing at baseline and with available follow-up audiograms. RESULTS The median VS tumor volume was 1.4 cm3, and the median length of follow-up was 5.1 years. Actuarial 5-and 10-year tumor control rates were 91.3% and 84.8%, respectively. Only tumor volume was a statistically significant predictor of tumor control rate. The tumor control rate decreased from 94.1% for tumors smaller than 0.5 cm3 to 80.7% for tumors larger than 6 cm3. Thirteen patients (3.1%) had new or increased permanent trigeminal nerve neuropathy, 4 (1.0%) had new or increased permanent facial weakness, and 5 (1.2%) exhibited new or increased hydrocephalus requiring a shunting procedure. Actuarial 3-year and 5-year hearing preservation rates were 65% and 42%, respectively. CONCLUSIONS The 5-year actuarial tumor control rate of 91.3% in this cohort of patients with VS compared slightly unfavorably with the rates reported in other large studies, but the complication and hearing preservation rates in this study were similar to those reported previously. Various factors may contribute to the observed differences in reported outcomes. These factors include variations in treatment indication and in the definition of treatment failure, as well as a lack of standardization of terminology and of evaluation of complications. Last, differences in dosimetric variables may also be an explanatory factor.

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PC3 - 142 Gamma Knife Radiosurgery in Patients with Persistent Acromegaly or Cushing’s Disease: Long-Term Risk of Hypopituitarism

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2016.393 ◽

2016 ◽

Vol 43 (S4) ◽

pp. S22-S22

Author(s):

O. Cohen-Inbar

Keyword(s):

Gamma Knife ◽

Cavernous Sinus ◽

Cushing’S Disease ◽

Hormone Replacement ◽

Gamma Knife Radiosurgery ◽

Common Adverse Effect ◽

Cushing's Disease ◽

Pituitary Hormone

For patient with a recurrent or residual acromegaly or Cushing’s disease (CD) after resection, Gamma knife radiosurgery (GKRS) is often used. Hypopituitarism is the most common adverse effect after GKRS treatment. The paucity of studies with long-term follow up has hampered understanding of the latent risks of hypopituitarism in patients with a Acromegaly or CD. We report the long-term risks of hypopituitarism for patients treated with GKRS for Acromegaly or CD. Methods: From a prospectively created, IRB approved database, we identified all patients with a Acromegaly or CD treated with GKRS at the University of Virginia from 1989 to 2008. Only patients with a minimum endocrine follow up of 60 months were included. The median follow-up is 159.5 months (60.1-278). Thorough radiological and endocrine assessments were performed immediately before GKRS and at regular follow-up intervals. New onset of hypopituitarism was defined as pituitary hormone deficits after GKRS requiring corresponding hormone replacement. Results: 60 patients with either Acromegaly or CD were included. Median tumor volume at time of GKRS was 1.3 cm3 (0.3-13.4), median margin dose was 25 Gy (6-30). GKRS induced new pituitary deficiency occurred in 58.3% (n=35) of patients. Growth Hormone deficiency was most common (28.3%, n=17). The actuarial overall rates of hypopituitarism at 3, 5, and 10 years were 10%, 21.7%, and 53.3%, respectively. The median time to hypopituitarism was 61 months after GKRS (range, 12-160). Cavernous sinus invasion of the tumor was found to correlate with the occurrence of a new or progressive hypopituitarism after GKRS (p=0.018). Conclusions: Delayed hypopituitarism increases as a function of time after radiosurgery. Hormone axes appear to vary in terms of radiosensitivity. Patients with adenoma in the cavernous sinus are more prone to develop loss of pituitary function after GKRS.

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Characteristic of Tumor Regrowth After Gamma Knife Radiosurgery and Outcomes of Repeat Gamma Knife Radiosurgery in Nonfunctioning Pituitary Adenomas

Frontiers in Oncology ◽

10.3389/fonc.2021.627428 ◽

2021 ◽

Vol 11 ◽

Author(s):

Yanli Li ◽

Lisha Wu ◽

Tingting Quan ◽

Junyi Fu ◽

Linhui Cao ◽

...

Keyword(s):

Gamma Knife ◽

Key Management ◽

Pituitary Adenomas ◽

Gamma Knife Radiosurgery ◽

Tumor Control ◽

Nonfunctioning Pituitary Adenomas ◽

Independent Risk Factors ◽

Tumor Regrowth ◽

Design And Methods

ObjectiveThis study aimed to report the characteristic of tumor regrowth after gamma knife radiosurgery (GKRS) and outcomes of repeat GKRS in nonfunctioning pituitary adenomas (NFPAs).Design and MethodsThis retrospective study consisted of 369 NFPA patients treated with GKRS. The median age was 45.2 (range, 7.2–84.0) years. The median tumor volume was 3.5 (range, 0.1–44.3) cm3.ResultsTwenty-four patients (6.5%) were confirmed as regrowth after GKRS. The regrowth-free survivals were 100%, 98%, 97%, 86% and 77% at 1, 3, 5, 10 and 15 year, respectively. In multivariate analysis, parasellar invasion and margin dose (<12 Gy) were associated with tumor regrowth (hazard ratio [HR] = 3.125, 95% confidence interval [CI] = 1.318–7.410, p = 0.010 and HR = 3.359, 95% CI = 1.347–8.379, p = 0.009, respectively). The median time of regrowth was 86.1 (range, 23.2–236.0) months. Previous surgery was associated with tumor regrowth out of field (p = 0.033). Twelve patients underwent repeat GKRS, including regrowth in (n = 8) and out of field (n = 4). Tumor shrunk in seven patients (58.3%), remained stable in one (8.3%) and regrowth in four (33.3%) with a median repeat GKRS margin dose of 12 (range, 10.0–14.0) Gy. The actuarial tumor control rates were 100%, 90%, 90%, 68%, and 68% at 1, 3, 5, 10, and 15 years after repeat GKRS, respectively.ConclusionsParasellar invasion and tumor margin dose (<12 Gy) were independent risk factors for tumor regrowth after GKRS. Repeat GKRS might be effective on tumor control for selected patients. For regrowth in field due to relatively insufficient radiation dose, repeat GKRS might offer satisfactory tumor control. For regrowth out of field, preventing regrowth out of field was the key management. Sufficient target coverage and close follow-up might be helpful.

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PITUITARY ADENOMAS TREATED WITH GAMMA KNIFE RADIOSURGERY

Neurosurgery ◽

10.1227/01.neu.0000255519.96837.c7 ◽

2007 ◽

Vol 61 (2) ◽

pp. 270-280 ◽

Cited By ~ 37

Author(s):

M. Necmettin Pamir ◽

Türker Kiliç ◽

Muhittin Belirgen ◽

Ufuk Abacioğlu ◽

Nural Karabekiroğlu

Keyword(s):

Gamma Knife ◽

Cavernous Sinus ◽

Pituitary Adenomas ◽

Gamma Knife Radiosurgery ◽

Volumetric Analysis ◽

First Year ◽

Volume Changes ◽

Peripheral Dose ◽

Initial Volume

Abstract OBJECTIVE To analyze pituitary adenoma volume changes after gamma knife radiosurgery (GKRS) in patients with 3 years of follow-up and to investigate factors that might affect these changes. METHODS Between January 1997 and March 2004, a total of 1930 patients were treated in the Gamma Knife Unit of the Marmara University Department of Neurosurgery in Istanbul, Turkey. Three hundred sixty of these patients had pituitary adenomas (PAs). This prospectively designed clinical study documents the radiological-volumetric analysis for the first 100 of these patients with PAs who had a minimum of 3 years of follow-up and met the study requirements. Each tumor was assessed with serial magnetic resonance imaging scans after radiosurgery; at each time point, adenoma volume was expressed as a percentage of the tumor's initial volume. Volume changes were investigated relative to margin dose, the cavernous sinus infiltration, and endocrinological type of adenoma. RESULTS At the end of the first year after GKRS, the PA volumes had decreased to approximately 90% of the initial volume on average. The corresponding approximate averages for the ends of Years 2 and 3 were 80 and 70% of the initial volume, respectively. At 3 years after GKRS, the PAs in the group with a peripheral dose of less than 17 Gy were reduced to approximately 80% of the initial volume on average. In contrast, the tumors in the patients with marginal doses of 21 to 23 Gy were reduced to approximately 60% of the initial volume at this stage. The adenomas treated with the highest marginal doses (>27 Gy) showed the earliest volume decreases after GKRS (6–9 mo after the procedure). Cavernous sinus noninfiltrating adenomas showed greater volume decreases after GKRS; on average, these masses were reduced to approximately 50% of their initial volume at 3 years. In contrast, the PAs that had infiltrated the cavernous sinus had only dropped to approximately 80% of their initial volume at this stage. The growth hormone-secreting PAs showed the maximum volume decrease with GKRS. On average, these lesions were approximately 60% of their initial volume at the 3-year stage. The nonfunctioning tumors and the prolactin-secreting adenomas showed similar volume changes over time. On average, these tumors had dropped to approximately 75 and 70% of the initial volume, respectively, by 3 years after GKRS. CONCLUSION Gamma knife radiosurgery halts the growth of pituitary adenomas. Cavernous sinus extension and margin dose are the most important determinants of adenoma volume after this type of therapy.

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Gamma Knife surgery for adrenocorticotropic hormone–producing pituitary adenomas after bilateral adrenalectomy

Journal of Neurosurgery ◽

10.3171/jns.2007.106.6.988 ◽

2007 ◽

Vol 106 (6) ◽

pp. 988-993 ◽

Cited By ~ 43

Author(s):

William J. Mauermann ◽

Jason P. Sheehan ◽

Daniel R. Chernavvsky ◽

Edward R. Laws ◽

Ladislau Steiner ◽

...

Keyword(s):

Pituitary Adenoma ◽

Gamma Knife ◽

Pituitary Adenomas ◽

Cranial Nerve ◽

Adrenocorticotropic Hormone ◽

Gamma Knife Surgery ◽

Nelson’S Syndrome ◽

Nelson's Syndrome ◽

Follow Up Studies

Object Patients with adrenocorticotropic hormone (ACTH)–secreting pituitary adenomas may require a bilateral adrenalectomy to treat their Cushing's disease. Approximately one third of these patients, however, will experience progressive enlargement of the residual pituitary adenoma, develop hyperpigmentation, and have an elevated level of serum ACTH. These patients with Nelson's syndrome can be treated with Gamma Knife surgery (GKS). Methods The prospectively collected University of Virginia Gamma Knife database of patients with pituitary adenomas was reviewed to identify all individuals with Nelson's syndrome who were treated with GKS. Twenty-three patients with a minimum of 6 months of follow up were identified in the database. These patients were assessed for tumor control (that is, lack of tumor growth over time) with neuroimaging studies (median follow-up duration 22 months) and for biochemical normalization of their ACTH levels (median follow-up duration 50 months). Neuroimaging follow-up studies were available for 22 patients, and endocrine follow up was available for 15 patients in whom elevation of ACTH levels was documented prior to GKS. In the 22 patients in whom neuroimaging follow-up studies were available, 12 had a decrease in tumor size, eight had no tumor growth, and two had an increase in tumor volume. Ten of 15 patients with elevated ACTH levels prior to GKS showed a decrease in their ACTH levels at last follow up; three of these 10 patients achieved normal ACTH levels (< 50 pg/ml) and the other five patients with initially elevated values had an increase in ACTH levels. Ten patients were thoroughly evaluated for post-GKS pituitary function; four were found to have new pituitary hormone deficiency and six did not have hypopituitarism after GKS. One patient suffered a permanent third cranial nerve palsy and four patients are now deceased. Conclusions Gamma Knife surgery may control the residual pituitary adenoma and decrease ACTH levels in patients with Nelson's syndrome. Delayed hypopituitarism or cranial nerve palsies can occur after GKS. Patients with Nelson's syndrome require continued multidisciplinary follow-up care. Given the difficulties associated with management of Nelson's syndrome, even the modest results of GKS may be helpful for a number of patients.

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Aggressive Cushing disease five years after the treatment of a nonfunctional pituitary adenoma

Problems of Endocrinology ◽

10.14341/probl201662577-78 ◽

2016 ◽

Vol 62 (5) ◽

pp. 77-78

Author(s):

Minodora Betivoiu ◽

Sorina Martin ◽

Iulia Soare ◽

Alexandra Nila ◽

Simona Fica

Keyword(s):

Pituitary Adenoma ◽

Gamma Knife ◽

Pituitary Adenomas ◽

Histopathological Examination ◽

Case Reports ◽

Dependent Diabetes Mellitus ◽

Ki 67 ◽

The Right ◽

Gamma Knife Therapy

Introduction. Cushing's disease (CD) represents 10%–12% of all pituitary adenomas and is seen predominantly in women, with a female-to-male ratio of 8:1. Although most patients with ACTH-secreting adenomas present with benign, small tumors, some have invasive macroadenomas. Rarely, nonfunctional pituitary adenomas (NFPAs) may gain secretory function, but there have been a few case reports of metamorphosis to CD.Case report. We report the case of a 59-year-old female diagnosed in 2007 with a NFPA and panhypopituitarism. She had two transsphenoidal surgeries and Gamma Knife therapy and started replacement treatment with levothyroxine 75mcg/day and prednisone 5mg/day. The postoperative course was favorable and imagistic follow-up between 2007-2014 showed progressive reduction of the residual tumor and empty sella. From personal history we note noninsulin-dependent diabetes mellitus, postmenopausal osteoporosis treated with bisphosphonates. In January 2015 she suffered visual loss on the right eye. Pituitary MRI showed supra and parasellar tumor recurrence of 27/24/17mm, infiltrating the right side of the cavernous sinus, extending around the right internal carotid artery and optic nerve, compressing the optic chiasm. In March 2015 a third transsphenoidal partial excision of the tumor was performed and in August Gamma Knife therapy was repeated. The histopathological examination was consistent with a pituitary adenoma but immunohistochemical staining for ACTH was positive, with Ki-67=25%. She had no non-specific cushingoid features. Laboratory test: glucose=116mg/dl, HbA1c=7.5%, FSH=3.34mIU/ml, LH=0.585mIU/ml TSH=0.044mcIU/ml, FT4=1.13ng/dl. Prednisone replacement therapy was stopped and CD was confirmed: 8AMcortisol=13.3mcg/dl, 23PMcortisol=11.3mcg/dl, ACTH=70.2pg/ml, 8AMcortisol after 1mg dexamethasone overnight=13.8mcg/dl. Ophthalmic exam: blindness in the right eye, slightly decreased visual field in the left eye. Pituitary MRI 8-month postsurgery revealed a 28/31/28mm invasive tumor. We started treatment with Cabergoline 3mg/week and recommended closely biological and imagistic follow-up, hoping for a good response to radiotherapy.Conclusions: Our case stresses the importance of regular, lifelong follow-up of patients with NFPAs. Chiloiro et al have reported that pituitary adenomas with Ki-67≥1.5% have a higher risk of recurrence. Although the characteristics of patients with CD have been well known for decades, the diagnosis and management of this disease are often challenging.

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Gamma knife radiosurgery: a safe and effective salvage treatment for pituitary tumours not controlled despite conventional radiotherapy

Acta Endocrinologica ◽

10.1530/eje-09-0493 ◽

2009 ◽

Vol 161 (6) ◽

pp. 819-828 ◽

Cited By ~ 25

Author(s):

F M Swords ◽

J P Monson ◽

G M Besser ◽

S L Chew ◽

W M Drake ◽

...

Keyword(s):

Gamma Knife ◽

Pituitary Adenomas ◽

External Beam Radiotherapy ◽

Gamma Knife Radiosurgery ◽

Pituitary Surgery ◽

Disease Stabilisation ◽

Adjunctive Treatment ◽

Pituitary Hormone ◽

Conventional Radiotherapy ◽

Corticotroph Adenomas

ObjectiveWe report the use of ‘gamma knife’ (GK) radiosurgery in 25 patients with pituitary adenomas not cured despite conventional therapy, including external beam radiotherapy.Patients and methodsAll patients had previously received conventional radiotherapy for a mean of 11.8 years prior to receiving GK; 23 out of 25 had also undergone pituitary surgery on at least one occasion. Seventeen had hyperfunctioning adenomas that still required medical therapy without an adequate biochemical control – ten somatotroph adenomas, six corticotroph adenomas and one prolactinoma, while eight patients had non-functioning pituitary adenomas (NFPAs).ResultsFollowing GK, mean GH fell by 49% at 1 year in patients with somatotroph tumours. Serum IGF1 fell by 32% at 1 year and by 38% at 2 years. To date, 80% of the patients with acromegaly have achieved normalisation of IGF1, and 30% have also achieved a mean GH level of <1.8 ng/ml correlating with normalised mortality. A total of 75% NFPAs showed disease stabilisation or shrinkage post GK. The patient with a prolactinoma showed a dramatic response: 75% reduction in prolactin at 2 years, with a marked shrinkage on magnetic resonance imaging. The results in corticotroph adenomas were variable. Prior to GK, 72% of the patients were panhypopituitary, and 42% of the remainder have developed new anterior pituitary hormone deficiencies to date. No other adverse events have been detected at a mean follow-up of 36.4 months.ConclusionsThese data indicate that GK is a safe and effective adjunctive treatment for patients with NFPAs and acromegaly not satisfactorily controlled with surgery and radiotherapy.

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