The long‐term efficacy of conservative surgery and radiotherapy in the control of pituitary adenomas

Brada, Michael; Rajan, Balakrishnan; Traish, D.; Ashley, S.; Holmes-Sellors, P. J.; Nussey, Stephen; Uttley, David

doi:10.1111/j.1365-2265.1993.tb02137.x

Cited by 337 publications

(200 citation statements)

References 29 publications

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“…The risk of developing hormone insufficiency is persistent for up to more than 15 years after radiotherapy. Brada et al reported a need for hormonal replacement therapy in 30% and 50% of patients 10 and 19 years after radiotherapy 16 . Optic neuropathy is a serious complication, but it is rare after fractionated radiotherapy to doses of 45-54 Gy; Parsons et al reported no optic nerve injuries in 106 optic nerves that received a total radiation dose of less than 59 Gy 17 .…”

Section: Discussionmentioning

confidence: 99%

Fractionated Stereotactic Radiotherapy in the Treatment of Pituitary Macroadenomas

et al. 2008

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BackgroundThe use of fractionated stereotactic radiotherapy (FSRT) has evolved with technical advances in noninvasive immobilization, radiation delivery, and image guidance. The application of FSRT to pituitary tumours is aimed at reducing toxicity through improved dose conformality and reduced treatment margins. The aim of the present paper is to report our own experience and to review the published data on FSRT for pituitary macroadenomas. MethodsBetween September 2000 and October 2005, 13 patients with pituitary macroadenoma underwent FSRT at our institution. In 12 patients, radiotherapy treatment followed surgical resection (transsphenoidal resection in 8, frontal craniotomy in 3, and multiple transsphenoidal resections followed by craniotomy in 1). In 4 patients, the tumours were functional (2 adrenocorticotropic hormone-secreting, 1 prolactinoma, and 1 growth hormone-secreting); the tumours in the remaining patients were clinically non-secretory. Before radiation, 3 patients had panhypopituitarism, and 6 patients had visual field defects. All patients were treated with FSRT using non-coplanar micro-multileaf collimation portals. A median dose of 50.4 Gy (range: 45-60 Gy) was prescribed to the 76.9%-95.2% isodose surface and delivered in 1.8-Gy fractions. The median planning target volume (gross tumour plus 3 mm) was 33.5 cm 3 (range: 3.2-75 cm 3 ). ResultsAfter a median follow-up of 24 months (range: 6-60 months), local control was 100%. One patient achieved clinical complete response. Treatment was well tolerated acutely for all patients. Neither radiation-induced optic neuropathy nor any radiation-related endocrine dysfunction was observed in our patients. ConclusionsIn accordance with published series, we found FSRT to be safe and effective in the management of large pituitary macroadenomas.

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Section: Discussionmentioning

confidence: 99%

Fractionated Stereotactic Radiotherapy in the Treatment of Pituitary Macroadenomas

et al. 2008

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“…Our group and others have described preoperative factors that can impact the recurrence of some pituitary lesions, 9,15,19 while others have shown the impact of postoperative radiation therapy for the prevention of recurrence. 3,20 Numerous groups have described remission rates associated with repeat transsphenoidal surgery for endocrine active and inactive pituitary lesions, 1,21 and these studies have also described the morbidity of repeat transsphenoidal surgery, but no study to date has compared the morbidity of repeat transsphenoidal surgery with that of initial transsphenoidal surgery for the variety of pathologies seen in a large pituitary practice or after prior radiation therapy.…”

Section: ©Aans 2014mentioning

confidence: 99%

Morbidity of repeat transsphenoidal surgery assessed in more than 1000 operations

Jahangiri¹,

Wagner²,

Han³

et al. 2014

JNS

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Object. While transsphenoidal surgery is associated with low morbidity, the degree to which morbidity increases after reoperation remains unclear. The authors determined the morbidity associated with repeat versus initial transsphenoidal surgery after 1015 consecutive operations.Methods. The authors conducted a 5-year retrospective review of the first 916 patients undergoing transsphenoidal surgery at their institution after a pituitary center of expertise was established, and they analyzed morbidities.Results. The authors analyzed 907 initial and 108 repeat transsphenoidal surgeries performed in 916 patients (9 initial surgeries performed outside the authors' center were excluded). The most common diagnoses were endocrine inactive (30%) or active (36%) adenomas, Rathke's cleft cysts (10%), and craniopharyngioma (3%). Morbidity of initial surgery versus reoperation included diabetes insipidus ([DI] 16% vs 26%; p = 0.03), postoperative hyponatremia (20% vs 16%; p = 0.3), new postoperative hypopituitarism (5% vs 8%; p = 0.3), CSF leak requiring repair (1% vs 4%; p = 0.04), meningitis (0.4% vs 3%; p = 0.02), and length of stay ([LOS] 2.8 vs 4.5 days; p = 0.006). Of intraoperative parameters and postoperative morbidities, 1) some (use of lumbar drain and new postoperative hypopituitarism) did not increase with second or subsequent reoperations (p = 0.3-0.9); 2) some (DI and meningitis) increased upon second surgery (p = 0.02-0.04) but did not continue to increase for subsequent reoperations (p = 0.3-0.9); 3) some (LOS) increased upon second surgery and increased again for subsequent reoperations (p < 0.001); and 4) some (postoperative hyponatremia and CSF leak requiring repair) did not increase upon second surgery (p = 0.3) but went on to increase upon subsequent reoperations (p = 0.001-0.02). Multivariate analysis revealed that operation number, but not sex, age, pathology, radiation therapy, or lesion size, increased the risk of CSF leak, meningitis, and increased LOS. Separate analysis of initial versus repeat transsphenoidal surgery on the 2 most common benign pituitary lesions, pituitary adenomas and Rathke's cleft cysts, revealed that the increased incidence of DI and CSF leak requiring repair seen when all pathologies were combined remained significant when analyzing only pituitary adenomas and Rathke's cleft cysts (DI, 13% vs 35% [p = 0.001]; and CSF leak, 0.3% vs 9% [p = 0.0009 ]).Conclusions. Repeat transsphenoidal surgery was associated with somewhat more frequent postoperative DI, meningitis, CSF leak requiring repair, and greater LOS than the low morbidity characterizing initial transsphenoidal surgery. These results provide a framework for neurosurgeons in discussing reoperation for pituitary disease with their patients.

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“…4,[23][24][25][26]28,33,35,37,45,[47][48][49][51][52][53]61,65 Stereotactic radiosurgery helps reduce some of the risks of conventional radiotherapy, including hypopituitarism, radiation-induced tumors, carotid stenosis, and stroke, as well as neurocognitive side effects. 1,30,38,39,56 Gamma Knife radiosurgery (GKRS) is highly effective at preventing radiographic progression of residual and recurrent adenomas. Most large radiosurgical series demonstrate a tumor control rate approaching 90%.…”

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confidence: 99%

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

Pomeraniec¹,

Dallapiazza²,

Xu³

et al. 2016

JNS

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N oNfuNctioNiNg pituitary adenomas constitute approximately 15% to 30% of pituitary tumors 10,16 and typically present with symptoms of mass effect, including vision loss, headaches, and hypopituitarism from compression of the normal pituitary gland. Selective adenomectomy via a transsphenoidal approach remains the primary treatment modality by providing decompression and the prospect for cure. Complete resection rates vary significantly and can be limited due to tumor size and propensity for microscopic invasion of the surrounding structures. 2,5,31,32,43,56 Previously reported long-term outcomes following transsphenoidal surgery for nonfunctioning macroadenomas suggest that even gross-total resection carries a 10% to 20% rate of tumor recurrence at distant follow-up. 6,8,9,13,19,21,34,43,46,58,64,66 Subtotal resection without adjuvant treatment reportedly results in the progression of adenoma growth in 50% to 60% of patients within 10 years of surgery. 9,22,34,43,46,48 For these reasons, patients with nonfunctioning tumors may undergo secondary operations and/ or adjuvant radiotherapy for the treatment of residual or progressive disease. obJective Gamma Knife radiosurgery (GKRS) is frequently employed to treat residual or recurrent nonfunctioning pituitary macroadenomas. There is no consensus as to whether GKRS should be used early after surgery or if radiosurgery should be withheld until there is evidence of radiographic progression of tumor. methods This is a retrospective review of patients with nonfunctioning pituitary macroadenomas who underwent transsphenoidal surgery followed by GKRS between 1996 and 2013 at the University of Virginia Health System. Patients were stratified based on the interval between resection and radiosurgery. Operative results and imaging and clinical outcomes were compared across groups following early (≤ 6 months) or late (> 6 months) radiosurgery. results Sixty-four patients met the study criteria and were grouped based on early (n = 32) or late (n = 32) GKRS following transsphenoidal resection. There was a greater risk of tumor progression after GKRS in the late radiosurgical group (p = 0.027) over a median radiographic follow-up period of 68.5 months. Furthermore, there was a significantly higher occurrence of post-GKRS endocrinopathy in the late radiosurgical cohort (p = 0.041). Seventeen percent of patients without endocrinopathy in the early cohort developed new endocrinopathies during the follow-up period versus 64% in the late cohort (p = 0.036). This difference was primarily due to a significantly higher rate of tumor growth during the observation period of the late treatment cohort (p = 0.014). Of these patients with completely new endocrinopathies, radiation-associated pituitary insufficiency developed in 1 of 2 patients in the early group and in 3 of 7 (42.9%) patients in the late group. coNclusioNs Early treatment with GKRS appears to decrease the rate of radiographic and symptomatic progression of subtotally resected nonfunctioning pituitary macroadenomas compared w...

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The long‐term efficacy of conservative surgery and radiotherapy in the control of pituitary adenomas

Abstract: Conventional external beam radiotherapy as described here combined with conservative surgery is safe and effective in the control of pituitary adenomas. These results should form a baseline for comparison with new treatment strategies.

Cited by 337 publications

References 29 publications

Fractionated Stereotactic Radiotherapy in the Treatment of Pituitary Macroadenomas

Fractionated Stereotactic Radiotherapy in the Treatment of Pituitary Macroadenomas

Morbidity of repeat transsphenoidal surgery assessed in more than 1000 operations

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

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