Stereotactic radiosurgery for pituitary adenomas: an intermediate review of its safety, efficacy, and role in the neurosurgical treatment armamentarium

2005 ◽  
Vol 102 (4) ◽  
pp. 678-691 ◽  
Author(s):  
Jason P. Sheehan ◽  
Ajay Niranjan ◽  
Jonas M. Sheehan ◽  
John A. Jane ◽  
Edward R. Laws ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Pituitary Adenomas ◽  
Growth Control ◽  
Primary Treatment ◽  
Content Type ◽  
Fractionated Radiotherapy ◽  
Primary Treatment Modality ◽  
Number Of Patients ◽  
Neurosurgical Treatment ◽  
Fine Print

Object. Pituitary adenomas are very common neoplasms, constituting between 10 and 20% of all primary brain tumors. Historically, the treatment armamentarium for pituitary adenomas has included medical management, microsurgery, and fractionated radiotherapy. More recently, radiosurgery has emerged as a viable treatment option. The goal of this research was to define more fully the efficacy, safety, and role of radiosurgery in the treatment of pituitary adenomas. Methods. Medical literature databases were searched for articles pertaining to pituitary adenomas and stereotactic radiosurgery. Each study was examined to determine the number of patients, radiosurgical parameters (for example, maximal dose and tumor margin dose), duration of follow-up review, tumor growth control rate, complications, and rate of hormone normalization in the case of functioning adenomas. A total of 35 peer-reviewed studies involving 1621 patients were examined. Radiosurgery resulted in the control of tumor size in approximately 90% of treated patients. The reported rates of hormone normalization for functioning adenomas varied substantially. This was due in part to widespread differences in endocrinological criteria used for the postradiosurgical assessment. The risks of hypopituitarism, radiation-induced neoplasia, and cerebral vasculopathy associated with radiosurgery appeared lower than those for fractionated radiation therapy. Nevertheless, further observation will be required to understand the true probabilities. The incidence of other serious complications following radiosurgery was quite low. Conclusions. Although microsurgery remains the primary treatment modality in most cases, stereotactic radiosurgery offers both safe and effective treatment for recurrent or residual pituitary adenomas. In rare instances, radiosurgery may be the best initial treatment for patients with pituitary adenomas. Further refinements in the radiosurgical technique will likely lead to improved outcomes.

Dose—response tolerance of the visual pathways and cranial nerves of the cavernous sinus to stereotactic radiosurgery

1998 ◽  
Vol 88 (1) ◽  
pp. 43-50 ◽  
Author(s):  
Klaus A. Leber ◽  
Jutta Berglöff ◽  
Gerhard Pendl
Keyword(s):  
Stereotactic Radiosurgery ◽  
Cavernous Sinus ◽  
Dose Response ◽  
Cranial Nerves ◽  
Visual Pathways ◽  
Content Type ◽  
Number Of Patients ◽  
Response Tolerance ◽  
Fine Print

As the number of patients treated with stereotactic radiosurgery increases, it becomes particularly important to define with precision adverse effects on distinct structures of the nervous system. Object. This study was designed to assess the dose—response tolerance of the visual pathways and cranial nerves after exposure of the cavernous sinus to radiation. Methods. A total of 66 sites in the visual system and 210 cranial nerves of the middle cranial fossa were investigated in 50 patients who had undergone gamma knife treatment for benign skull base tumors. The mean follow-up period was 40 months (range 24–60 months). Follow-up examinations consisted of neurological, neuroradiological, and neuroophthalmological evaluations. The actuarial incidence of optic neuropathy was zero for patients who received a radiation dose of less than 10 Gy, 26.7% for patients receiving a dose in the range of 10 to less than 15 Gy, and 77.8% for those who received doses of 15 Gy or more (p < 0.0001). Previously impaired vision improved in 25.8% and was unchanged in 51.5% of patients. No sign of neuropathy was seen in patients whose cranial nerves of the cavernous sinus received radiation doses of between 5 and 30 Gy. Because tumor control appeared to have been achieved in 98% of the patients, the deterioration in visual function cannot be attributed to tumor progression. Conclusions. The structures of the visual pathways (the optic nerve, chiasm, and tract) exhibit a much higher sensitivity to single-fraction radiation than other cranial nerves, and their particular dose—response characteristics can be defined. In contrast, the oculomotor and trigeminal nerves have a much higher dose tolerance.

Stereotactic Radiosurgery as an Alternative to Fractionated Radiotherapy for Patients with Recurrent or Residual Nonfunctioning Pituitary Adenomas

Neurosurgery ◽  
2003 ◽  
Vol 53 (5) ◽  
pp. 1086-1094 ◽  
Author(s):  
Bruce E. Pollock ◽  
Paul C. Carpenter
Keyword(s):  
Stereotactic Radiosurgery ◽  
Pituitary Adenomas ◽  
Anterior Pituitary ◽  
Growth Control ◽  
Tumor Control ◽  
Fractionated Radiotherapy ◽  
Nonfunctioning Pituitary Adenomas ◽  
Early Results ◽  
Anterior Pituitary Function ◽  
Radiation Induced

Abstract OBJECTIVE To evaluate tumor control rates and complications after stereotactic radiosurgery for patients with nonfunctioning pituitary adenomas. METHODS Between 1992 and 2000, 33 patients underwent radiosurgery for treatment of nonfunctioning pituitary adenomas. Thirty-two patients (97%) had undergone one or more previous tumor resections. Twenty-two patients (67%) had enlarging tumors before radiosurgery. The median tumor margin dose was 16 Gy (range, 12–20 Gy). The median follow-up period after radiosurgery was 43 months (range, 16–106 mo). RESULTS Tumor size decreased for 16 patients, remained unchanged for 16 patients, and increased for 1 patient. The actuarial tumor growth control rates at 2 and 5 years after radiosurgery were 97%. No patient demonstrated any decline in visual function. Five of 18 patients (28%) with anterior pituitary function before radiosurgery developed new deficits, at a median of 24 months after radiosurgery. The actuarial risks of developing new anterior pituitary deficits were 18 and 41% at 2 and 5 years, respectively. No patient developed diabetes insipidus. CONCLUSION Stereotactic radiosurgery safely provides a high tumor control rate for patients with recurrent or residual nonfunctioning pituitary adenomas. However, despite encouraging early results, more long-term information is needed to determine whether radiosurgery is associated with lower risks of new endocrine deficits and radiation-induced neoplasms, compared with fractionated radiotherapy.

Stereotactic radiosurgery for recurrent surgically treated acromegaly: comparison with fractionated radiotherapy

1998 ◽  
Vol 88 (6) ◽  
pp. 1002-1008 ◽  
Author(s):  
Alex M. Landolt ◽  
Dieter Haller ◽  
Nicoletta Lomax ◽  
Stefan Scheib ◽  
Othmar Schubiger ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
Distribution Functions ◽  
Cumulative Distribution ◽  
Rank Test ◽  
Content Type ◽  
Fractionated Radiotherapy ◽  
Kaplan Meier ◽  
Fine Print

Object. The authors tested the assumption that gamma knife radiosurgery is more effective than fractionated radiotherapy for the treatment of patients with acromegaly who have undergone unsuccessful resective surgery. Untreated and uncured acromegaly causes illness and death. Acromegalic patients in whom growth hormone and, particularly, insulin-like growth factor I are not normalized must undergo further treatment. Methods. After unsuccessful operations, 16 patients suffering from recurrent and uncured acromegaly underwent stereotactic radiosurgery (25 Gy to the tumor margin, 50 Gy maximum), the outcome of which was compared with the result obtained in 50 patients who received fractionated radiotherapy (40 Gy). The cumulative distribution functions of the two groups (Kaplan—Meier estimate) differed significantly (p < 0.0001 in the log-rank test of Mantel). The mean time to simultaneous normalization of both parameters was 1.4 years in the group treated with the gamma knife and 7.1 years in the group treated with fractionated radiotherapy. Conclusions. The authors suggest the use of stereotactic radiosurgery as the preferred treatment for recurrent acromegaly resulting from unsuccessfully resected tumors.

Stabilization of disease progression by hydroxyurea in patients with recurrent or unresectable meningiomas

2002 ◽  
Vol 97 (2) ◽  
pp. 341-346 ◽  
Author(s):  
Warren P. Mason ◽  
Fred Gentili ◽  
David R. Macdonald ◽  
Subramanian Hariharan ◽  
Charlene R. Cruz ◽  
...  
Keyword(s):  
Stereotactic Radiosurgery ◽  
Residual Disease ◽  
Tumor Regression ◽  
Response To Therapy ◽  
Progression Rate ◽  
Malignant Meningioma ◽  
Content Type ◽  
Fractionated Radiotherapy ◽  
Atypical Meningiomas ◽  
Fine Print

Object. The management of certain meningiomas of the skull base and those involving the dural venous sinuses remains a challenge. In recent reports it has been suggested that hydroxyurea chemotherapy can cause regression of unresectable and recurrent meningiomas. The authors report their experience in using hydroxyurea for the treatment of patients with recurrent or unresectable meningiomas. Methods. Hydroxyurea was administered at a dosage of approximately 20 mg/kg/day to 11 women and nine men (median age 59 years, range 31–75 years) with recurrent or unresectable intracranial meningiomas (12 basal, two parasagittal, and six multiple). In 16 patients the meningiomas were benign, in three they had atypical features, and in one the meningioma was malignant. All patients had measurable residual disease. Four patients with benign meningiomas had previously received radiotherapy (two were treated with conventional fractionated radiotherapy and two with stereotactic radiosurgery), three with atypical meningiomas received conventional fractionated radiotherapy, and the one with a malignant meningioma received conventional radiotherapy with additional stereotactic radiosurgery. Tumor enlargement was documented in all patients on neuroimages obtained before initiation of hydroxyurea therapy. All patients were evaluable for response to therapy. In 12 patients with benign meningiomas, the disease had stabilized on neuroimages obtained posttreatment (median duration of treatment 122 weeks, range 8–151 weeks), and two of these showed clinical improvement. One patient with a benign meningioma experienced a minor partial response that was noted after 39 weeks of treatment and was confirmed on neuroimaging and clinical evaluations. In three others with benign meningiomas, progression was confirmed on neuroimages obtained after 41, 55, and 66 weeks, respectively; the 1-year freedom from progression rate was 0.93 (standard error 0.07) in patients with benign meningiomas. In three patients with atypical meningiomas, the tumors had progressed on neuroimages obtained after 12, 19, and 45 weeks, respectively. In the patient with a malignant meningioma, progression was confirmed on neuroimages obtained at 24 weeks. Hydroxyurea has been reasonably well tolerated, although one patient discontinued therapy because of moderate myelosuppression. Conclusions. Although tumor regression appears uncommon, these results indicate that hydroxyurea may arrest progression of unresectable or recurrent benign meningiomas.

Fulminant radiation-induced necrosis after stereotactic radiation therapy to the posterior fossa

2001 ◽  
Vol 95 (3) ◽  
pp. 507-512 ◽  
Author(s):  
Nitin Tandon ◽  
Dennis G. Vollmer ◽  
Pamela Z. New ◽  
James M. Hevezi ◽  
Terence Herman ◽  
...  
Keyword(s):  
Radiation Therapy ◽  
Primary Treatment ◽  
Normal Brain ◽  
Target Area ◽  
Stereotactic Irradiation ◽  
Content Type ◽  
Stereotactic Radiation ◽  
Primary Treatment Modality ◽  
Radiation Induced ◽  
Fine Print

✓ The problem of radiation-induced necrosis of normal brain surrounding the target area has been a major catalyst for the development of stereotactically focused radiation therapy. According to current opinion, the effects of stereotactic irradiation are confined to the region targeted. The authors present a case in which the administration of a conventional dose of stereotactically focused irradiation for treatment of a pilocytic astrocytoma produced fulminant necrosis that necessitated a combination of intensive surgical and medical management, after which the patient improved over the course of 1 year. Concomitant with his improvement, the initially remarkable findings on magnetic resonance imaging gradually resolved. In this presentation the authors emphasize the need to evaluate alternatives carefully before a decision is made to administer therapeutic irradiation. Furthermore, they explore the roles that target, host, and dosage factors play in hypersensitivity to radiation injury, the detection of these factors before treatment, and the administration of radioprotective agents. With the growing use of stereotactically focused irradiation as a primary treatment modality for a variety of neurosurgical conditions, it is important to be cognizant of its uncommon but potentially lethal side effects. A cooperative multicenter database in which the outcomes and morbidity following stereotactic irradiation are recorded is essential to the detection of relatively uncommon but severe complications such as those observed in this case.

Gamma surgery for vestibular schwannoma

2000 ◽  
Vol 92 (5) ◽  
pp. 745-759 ◽  
Author(s):  
Dheerendra Prasad ◽  
Melita Steiner ◽  
Ladislau Steiner
Keyword(s):  
Vestibular Schwannoma ◽  
Computer Software ◽  
Primary Treatment ◽  
Facial Paresis ◽  
Content Type ◽  
Primary Treatment Modality ◽  
Case Surgery ◽  
Volume Measurements ◽  
Fine Print

Object. The goal of this study was to assess the results of gamma surgery (GS) for vestibular schwannoma (VS) in 200 cases treated over the last 10 years and to review the role of this neurosurgical procedure in the management of VS.Methods. Follow-up reviews ranging from 1 to 10 years were available in 153 of these patients. Follow-up images in these cases were analyzed using computer software that we developed to obtain volume measurements for the tumors, and the clinical condition of the patients was assessed using questionnaires.Gamma surgery was the primary treatment modality in 96 cases and followed microsurgery in 57 cases. Tumors ranged in volume from 0.02 to 18.3 cm3. In the group in which GS was the primary treatment, a decrease in volume was observed in 78 cases (81%), no change in 12 (12%), and an increase in volume in six cases (6%). The decrease was more than 75% in seven cases. In the group treated following microsurgery, a decrease in volume was observed in 37 cases (65%), no change in 14 (25%), and an increase in volume in six (11%). The decrease was more than 75% in eight cases. Five patients experienced trigeminal dysfunction; in three cases this was transient and in the other two it was persistent, although there has been improvement. Three patients had facial paresis (in one case this was transient, lasting 6 weeks; in one case there was 80% recovery at 18 months posttreatment; and in one case surgery was performed after the onset of facial paresis for presumed increase in tumor size). Over a 6-year period, hearing deteriorated in 60% of the patients. Three patients showed an improvement in hearing. No hearing deterioration was observed during the first 2 years of follow-up review.Conclusions. Gamma surgery should be used to treat postoperative residual tumors as well as tumors in patients with medical conditions that preclude surgery. Microsurgery should be performed whenever a surgeon is confident of extirpating the tumor with a risk—benefit ratio superior to that presented in this study.

Stereotactic radiosurgery for glioblastoma: a final report of 31 patients

1995 ◽  
Vol 82 (4) ◽  
pp. 530-535 ◽  
Author(s):  
Jeffery E. Masciopinto ◽  
Allan B. Levin ◽  
Minesh P. Mehta ◽  
Blair S. Rhode
Keyword(s):  
Stereotactic Radiosurgery ◽  
Scale Score ◽  
Three Dimensional ◽  
Primary Treatment ◽  
Karnofsky Performance Scale ◽  
Final Report ◽  
Content Type ◽  
Karnofsky Performance Scale Score ◽  
Performance Scale ◽  
Fine Print

✓ From February 1989 to December 1992, 31 patients who presented with an initial pathological diagnosis of glioblastoma multiforme underwent tumor debulking or biopsy, stereotactic radiosurgery, and standard radiation therapy as part of their primary treatment. Presenting characteristics in the 22 men and nine women included a median age of 57 years, Karnofsky Performance Scale score median of 80, and median tumor volume of 16.4 cm3. Stereotactic radiosurgery delivered a central dose of 15 to 35 Gy with the isocenter location, collimator size, and beam paths individualized by means of three-dimensional software developed at the University of Wisconsin. The peripheral isodose line varied from 40% to 90% with a median of 72.5% and a mode of 80%. The mean follow-up period was 12.84 months with a median of 9.5 months. Statistical analysis was performed using Kaplan—Meier analysis and log-rank comparison of risk factor groups. The parameters of age, initial Karnofsky Performance Scale score, and biopsy were significantly different in patient survival from debulking; but no difference was noted between single and multiple isocenters and patterns of steroid requirement. Radiographic recurrences were divided by location into the following categories: central (within central stereotactic radiosurgery dose), 0; peripheral (within 2 cm of central dose), 19; and distant (> 2 cm), 4. There is no evidence of recurrence in five surviving patients. Actuarial 12-month survival was 37%, with a median survival of 9.5 months. These values are similar to previous results for surgery and standard radiotherapy alone.22 The results suggest that the curative value of radiosurgery is significantly limited by peripheral recurrences.

Stereotactic radiosurgery for pituitary adenoma invading the cavernous sinus

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 2-5 ◽  
Author(s):  
Masahiro Shin ◽  
Hiroki Kurita ◽  
Tomio Sasaki ◽  
Masao Tago ◽  
Akio Morita ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Pituitary Adenomas ◽  
Gamma Knife Radiosurgery ◽  
Growth Control ◽  
Urinary Free Cortisol ◽  
Content Type ◽  
Conventional Radiation ◽  
Free Cortisol ◽  
Radiation Induced ◽  
Fine Print

Object. The purpose of this study is to determine the efficacy of gamma knife radiosurgery (GKS) treatment of pituitary adenomas that have invaded the cavernous sinus. Methods. Sixteen patients were treated with GKS: three with nonfunctional adenomas and 13 with hormone-secreting (seven growth hormone [GH] and six adrenocorticotropic hormone [ACTH]) adenomas. More than 16 Gy and 30 Gy were delivered to the tumor margin for nonfunctioning tumors and functioning tumors, respectively, keeping the dose to the optic pathways below 10 Gy. The median follow up was 3 years. Tumor growth control was achieved in all cases. In GH-producing tumors, four of six cases evaluated were endocrinologically normalized (serum GH < 10 mIU/L, somatomedin C < 450 ng/ml), and the remaining two cases also showed a steady decrease in the GH and somatomedin level. In ACTH-producing tumors, three of six cases were endocrinologically normalized (24-hour urinary-free cortisol < 90 mg/day), two were unchanged, and one showed hormonal recurrence 3 years after radiosurgery. Notably, there were no cases of permanent hypopituitarism or visual symptoms caused by radiosurgery. Conclusions. The authors data indicate that GKS can be a safe salvage therapy for invading pituitary adenomas, with effectiveness equivalent to conventional radiation therapy but with less risk of causing radiation-induced injury to the surrounding structures.

Efficacy of gamma knife radiosurgery for nonfunctioning pituitary adenomas: a quantitative follow up with magnetic resonance imaging—based volumetric analysis

2002 ◽  
Vol 97 ◽  
pp. 429-432 ◽  
Author(s):  
Berndt Wowra ◽  
Walter Stummer
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Pituitary Adenomas ◽  
Gamma Knife Radiosurgery ◽  
Volumetric Analysis ◽  
Resonance Imaging ◽  
Content Type ◽  
Fractionated Radiotherapy ◽  
Fine Print

Object. The authors assessed the efficacy of gamma knife radiosurgery (GKS) for nonfunctioning pituitary adenomas (NPAs) by sequential quantitative determinations of tumor volume and neurological and endocrinological follow-up examinations. Methods. Through May of 2000, 45 patients with NPA were treated by GKS. Complete neurological and endocrinological follow-up information was obtained. In 30 patients (67%), follow-up examinations included stereotactic magnetic resonance imaging involving the GammaPlan software for sequential measurements of the NPA volume. These patients constitute the basis of this study. Sequential volume measurements after GKS were compared with initial tumor volumes at the date of GKS to quantify the therapeutic result. All data were stored prospectively in a computerized database. The median dose to the tumor margin was 16 Gy (range 11–20 Gy). The mean prescription isodose was 55% (range 45–75%). All except one patient (97%) underwent surgery for NPA before GKS. Fractionated radiotherapy was not administered. Median follow up after GKS was 55 months (range 28–86 months). The actuarial long-term recurrence-free survival was 93% with respect to a single GKS and 100% if a repeated GKS was included. Neurological side effects were not detected. The actuarial risk of radiosurgery-induced pituitary damage was calculated to be 14% after 6 years. The volumetric analysis revealed a temporary swelling of the NPA in four patients, followed by shrinkage of the lesion. This is the first time this has been observed in pituitary adenomas. Conclusions. Postoperative GKS for residual or recurrent small fragments of NPAs is effective and safe. With regard to the issues of radioprotection and therapeutic morbidity, it seems superior to fractionated radiotherapy. Quantification of tumor reduction is a valuable tool for documenting a therapeutic response and for identifying tumor recurrence. As part of a radiosurgical standard protocol, the follow-up examination for NPAs should include tumor volumetric analysis.

Safety and efficacy of stereotactic radiosurgery for tumors of the spine

2004 ◽  
pp. 413-418 ◽  
Author(s):  
Deborah L. Benzil ◽  
Mehran Saboori ◽  
Alon Y. Mogilner ◽  
Ronald Rocchio ◽  
Chitti R. Moorthy
Keyword(s):  
Spinal Cord ◽  
Single Dose ◽  
Pain Relief ◽  
Total Dose ◽  
Stereotactic Radiosurgery ◽  
Medical Center ◽  
Primary Tumors ◽  
Content Type ◽  
Increased Risk ◽  
Fine Print

Object. The extension of stereotactic radiosurgery treatment of tumors of the spine has the potential to benefit many patients. As in the early days of cranial stereotactic radiosurgery, however, dose-related efficacy and toxicity are not well understood. The authors report their initial experience with stereotactic radiosurgery of the spine with attention to dose, efficacy, and toxicity. Methods. All patients who underwent stereotactic radiosurgery of the spine were treated using the Novalis unit at Westchester Medical Center between December 2001 and January 2004 are included in a database consisting of demographics on disease, dose, outcome, and complications. A total of 31 patients (12 men, 19 women; mean age 61 years, median age 63 years) received treatment for 35 tumors. Tumor types included 26 metastases (12 lung, nine breast, five other) and nine primary tumors (four intradural, five extradural). Thoracic tumors were most common (17 metastases and four primary) followed by lumbar tumors (four metastases and four primary). Lesions were treated to the 85 to 90% isodose line with spinal cord doses being less than 50%. The dose per fraction and total dose were selected on the basis of previous treatment (particularly radiation exposure), size of lesion, and proximity to critical structures. Conclusions. Rapid and significant pain relief was achieved after stereotactic radiosurgery in 32 of 34 treated tumors. In patients treated for metastases, pain was relieved within 72 hours and remained reduced 3 months later. Pain relief was achieved with a single dose as low as 500 cGy. Spinal cord isodoses were less than 50% in all patients except those with intradural tumors (mean single dose to spinal cord 268 cGy and mean total dose to spinal cord 689 cGy). Two patients experienced transient radiculitis (both with a biological equivalent dose (BED) > 60 Gy). One patient who suffered multiple recurrences of a conus ependymoma had permanent neurological deterioration after initial improvement. Pathological evaluation of this lesion at surgery revealed radiation necrosis with some residual/recurrent tumor. No patient experienced other organ toxicity. Stereotactic radiosurgery of the spine is safe at the doses used and provides effective pain relief. In this study, BEDs greater than 60 Gy were associated with an increased risk of radiculitis.

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