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Treatment of pituitary adenomas using radiosurgery and radiotherapy: a single center experience and review of literature

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Abstract

Fractionated radiotherapy (FRT) and gamma knife stereotactic radiosurgery (GKSRS) are used as adjuvant therapies to surgical resection for functional and non-functional pituitary adenomas, although their optimum role in the treatment algorithm, as well as long-term safety and efficacy, still awaits further study. We report a single center experience with 33 patients with non-functional (16 patients), ACTH- (five patients), GH- (four patients), or prolactin-secreting (eight patients) tumors treated with FRT or SRS. The median tumor diameter was 1.9 cm, and the median follow-up was 36 months. For GKSRS, the median dosage was 16 Gy for non-functional adenomas and 23 Gy for hormone-secreting tumors. The median total dose for FRT was 50.4 Gy over 28 fractions (median). Two patients (6%) demonstrated radiographic evidence of tumor progression, three patients (9%) demonstrated radiation-induced visual field deficits on neuro-ophthalmic evaluation, and two patients (6%) suffered from radiation-induced hypopituitarism. Biochemical control, defined as normalized hormone values in the absence of medical therapy, was achieved in five out of eight prolactinoma patients and two out of five patients with Cushing’s disease, but none of the four patients with acromegaly. These results are presented with a review of the relevant literature on the differential characteristics of FRT versus SRS in the treatment of functional and non-functional pituitary adenomas and validate postoperative irradiation as a potentially safe and effective means for tumor control.

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Acknowledgments

This work was supported in part by a grant from the Salisbury Foundation to DR.

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The authors in this manuscript have no conflicts of interest.

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Authors and Affiliations

  1. Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA

    Daniel Q. Sun, Jennifer J. Cheng, James L. Frazier, Sachin Batra, Daniele Rigamonti, Alfredo Quinones-Hinojosa & Michael Lim

  2. Department of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA

    Gary Wand & Roberto Salvatori

  3. Department of Radiation Oncology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, 21287, USA

    Lawrence R. Kleinberg, Daniele Rigamonti & Michael Lim

  4. Department of Neurosurgery and Oncology, Johns Hopkins University School of Medicine, Phipps 123, 600 N. Wolfe Street, Baltimore, MD, 21287, USA

    Michael Lim

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  1. Daniel Q. Sun
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Correspondence to Michael Lim.

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Comments

Miguel A. Arraez, Malaga, Spain

This paper carries out the study of 33 patients that underwent radiotherapy treatment for invasive or recurrent pituitary adenoma. In the recurrent tumor, the mainstay of treatment in such a situation is radiotherapy once reoperation has been ruled out (sterotactic fraccionated radiotherapy or stereotactic radiosurgery). These modalities have different context in accordance to the volume and proximity to critical organs like optic pathways. Although this study lacks of a large number of cases and long follow-up, it depicts the usefulness of these modalities of stereotactic radiation to control pituitary adenomas. The figures of control are in full accordance with the previous published articles for non-secreting tumors. In secreting pituitary adenomas, a very acceptable rate of biochemical control has been obtained. Some figures are in disagreement to the previously published data regarding the cure of acromegaly patients but, as the authors also stated, a longer period is needed to properly assess the usefulness of radiation therapy in GH-secreting tumors. Another issue of interest is the possibility of radiation without previous surgery. In this series, it was done after rejection of the surgical treatment for the patients. Undoubtedly, the debate about the possibility of elective radiation arises as first choice treatment for selected cases. The potential toxicity should be also taken into account. The 10% figures of delayed optic damage must lead us to the reflection for appropriate case selection and modality of treatment. The possibility of hypopituitarism mustn’t be forgotten whose low figures in this series are also attributed to a short follow-up.

Francesco DiMeco, Ida Milanesi, Marcello Marchetti, Milan, Italy

Radiation therapy for pituitary adenomas is still a debated and controversial topic. Previous reports have shown that conventional radiation is effective in tumor growth control and hormonal normalization.

Radiosurgery, while limiting irradiation and potential damages to the normal tissue, raises concerns about possible post-treatment hypopituitarism and visual function worsening. In addition, it carries potential risks of hyatrogenic tumors development or cognitive function impairment. The present article tries to address these issues showing good results with acceptable side effects. However, higher powered studies with longer follow-up are needed in order to corroborate these findings.

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Sun, D.Q., Cheng, J.J., Frazier, J.L. et al. Treatment of pituitary adenomas using radiosurgery and radiotherapy: a single center experience and review of literature. Neurosurg Rev 34, 181–189 (2011). https://doi.org/10.1007/s10143-010-0285-2

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  • DOI: https://doi.org/10.1007/s10143-010-0285-2

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