Pituitary

, 12:11 | Cite as

Cushing’s disease: radiation therapy

Article

Abstract

The usual first treatment for Cushing’s disease is surgical removal of the pituitary adenoma. In patients in whom surgery is unsuccessful or who decline an operation, radiation to the pituitary offers the possibility of remission. No form of radiation delivery results in immediate control of cortisol production. Thus, until radiation treatment becomes effective, medical therapy to lower cortisol production is indicated. The time to remission with radiation therapy cannot be predicted, medical therapy should be discontinued every 6 months to assess response to radiation treatment; a normal 24 h urine free cortisol being the optimal outcome. There are no prospective studies comparing the results among the different types of radiation delivery. The type of radiation delivery depends on several factors, including the availability of different treatment modalities and the size of the target area (focused high dose radiation with the Gamma knife is not suitable for a large lesion close to the optic nerves or optic chiasm). All types of radiation delivery cause loss of normal pituitary function and patients should be monitored regularly (every 6 months) for development of new hypopituitarism and appropriate hormone replacement(s). Complications of radiation therapy may include adverse effects on vision, normal brain tissue, and with older methods of fractionated radiation delivery, vasculopathy with an increased risk of cerebrovascular disease. Current use of more targeted methods of delivery will hopefully reduce this risk. If pituitary surgery is unsuccessful and the patient undergoes bilateral adrenalectomy, without pituitary radiation, there is a substantial risk, approximately 50% of patients, of development of Nelson’s syndrome (growth of pituitary adenoma, increase in serum ACTH, hyperpigmentation). There is a role for pituitary radiation in the treatment of patients with Cushing’s disease, most commonly as adjunctive therapy after unsuccessful pituitary surgery. Regular medical monitoring is necessary to determine the effectiveness of radiation therapy and development of new pituitary hormone deficiency.

Keywords

Cushing’s disease Multimodality therapies Radiation therapy Hypopituitarism 

References

  1. 1.
    Assie G, Bahurel H, Coste J et al (2007) Corticotroph tumor progression after adrenalectomy in Cushing’s disease: reappraisal of Nelson’s syndrome. J Clin Endocrinol Metab 92:172–179. doi: 10.1210/jc.2006-1328 PubMedCrossRefGoogle Scholar
  2. 2.
    Ahmed SR, Shalet SM, Beardwell CG, Sutton ML (1984) Treatment of Cushing’s disease with low dose radiation therapy. Br Med J (Clin Res Ed) 289:643–646Google Scholar
  3. 3.
    Littley MD, Shalet SM, Beardwell CG, Ahmen SR, Sutton ML (1990) Long-term follow-up of low dose pituitary irradiation from Cushing’s disease. Clin Endocrinol (Oxf) 33:445–455CrossRefGoogle Scholar
  4. 4.
    Tran LM, Blount L, Horton D, Sadeghi A, Parker RG (1991) Radiation therapy of pituitary tumors: results in 95 cases. Am J Clin Oncol 14:25–29. doi: 10.1097/00000421-199102000-00005 PubMedCrossRefGoogle Scholar
  5. 5.
    Tsang RW, Brierley JD, Panzarella T, Gospodarowicz MK, Sutcliffe SB, Simpson WJ (1996) Role of radiation therapy in clinical hormonally-active pituitary adenomas. Radiother Oncol 41:45–53. doi: 10.1016/S0167-8140(96)91807-1 PubMedCrossRefGoogle Scholar
  6. 6.
    Estrada J, Boronat M, Mielgo M et al (1997) The long-term outcome of pituitary irradiation after unsuccessful transsphenoidal surgery in Cushing’s disease. N Engl J Med 336:172–177. doi: 10.1056/NEJM199701163360303 PubMedCrossRefGoogle Scholar
  7. 7.
    Blevins LS, Christy JH, Khajavi M, Tindall GT (1998) Outcomes of therapy for Cushing’s disease due to adrenocorticotropin-secreting pituitary macroadenomas. J Clin Endocrinol Metab 83:63–67. doi: 10.1210/jc.83.1.63 PubMedCrossRefGoogle Scholar
  8. 8.
    Mahmoud-Ahmed AS, Suh JH (2002) Radiation therapy for Cushing’s disease: a review. Pituitary 5:175–180. doi: 10.1023/A:1023365200437 PubMedCrossRefGoogle Scholar
  9. 9.
    Colin P, Delemer CP, Nakib I et al (2002) Unsuccessful surgery in Cushing’s disease. Role and efficacy of fractionated stereotactic radiotherapy. Neurochirurgie 48:285–293PubMedGoogle Scholar
  10. 10.
    Devin JK, Allen GS, Cmelak AJ, Duggan DM, Blevins LS (2004) The efficacy of linear accelerator radiosurgery in the management of patients with Cushing’s disease. Stereotact Funct Neurosurg 82:254–262. doi: 10.1159/000083476 PubMedCrossRefGoogle Scholar
  11. 11.
    Petit JH, Biller BM, Yock TI et al (2007) Proton stereotactic radiotherapy for persistent ACTH-producing adenomas. J Clin Endocrinol Metab 20(Nov). Epub ahead of printGoogle Scholar
  12. 12.
    Degerblad M, Rahn T, Bergstrand G, Thoren M (1986) Long-term results of stereotactic radiosurgery to the pituitary gland in Cushing’s disease. Acta Endocrinol (Copenh) 112:310–314Google Scholar
  13. 13.
    Morange-Ramos I, Regis J, Dufour H et al (1998) Gamma-knife surgery for secreting pituitary adenomas. Acta Neurochir (Wien) 140:437–443. doi: 10.1007/s007010050121 CrossRefGoogle Scholar
  14. 14.
    Pollock BE, Nippoldt TB, Stafford SL, Foote RL, Abboud CF (2002) Results of stereotactic radiosurgery in patients with hormone-producing pituitary adenomas: factors associated with endocrine normalization. J Neurosurg 97:525–530PubMedCrossRefGoogle Scholar
  15. 15.
    Castinetti F, Nagai M, Dufour H et al (2007) Gamma knife radiosurgery is successful adjunctive treatment in Cushing’s disease. Eur J Endocrinol 156:91–98. doi: 10.1530/eje.1.02323 PubMedCrossRefGoogle Scholar
  16. 16.
    Jagannathan J, Sheehan JP, Pouratian N, Laws ER, Steiner L, Vance ML (2007) Gamma knife surgery for Cushing’s disease. J Neurosurg 106:980–987. doi: 10.3171/jns.2007.106.6.980 PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  1. 1.University of VirginiaCharlottesvilleUSA

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