Recent advances in pituitary tumor management

Winder, Mark J.; Mayberg, Marc R.

doi:10.1097/med.0b013e32834871f6

Cited by 9 publications

(5 citation statements)

References 137 publications

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“…Intraoperative MRI scans might ameliorate outcome in some patients but are not generally recommended [22,23]. Recently, stereotactic and fractional radiosurgery such as Gamma Knife or Cyber Knife have enriched interventional treatment options [24]. …”

Section: Recent Advancesmentioning

confidence: 99%

Advances in understanding pituitary tumors

2014

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Pituitary tumors are common in the general population. Since neuroimaging techniques have improved, pituitary tumors are more often diagnosed incidentally. About 16.7% of the general population show changes in the pituitary gland. Predominantly, pituitary tumors are benign pituitary adenomas. Pituitary carcinomas or aggressive pituitary tumors are extremely rare. They might develop from benign adenomas. New genetic and epigenetic abnormalities help us to understand pituitary tumorigenesis and might lead to therapeutical targeting drugs in the future. Macroadenomas (>1 cm) can lead to visual field disturbances, compression of cranial nerves, hypopituitarism, and infiltration of the cavernous sinuses. The functional status of the pituitary tumor is important. About half to one third of all pituitary tumors are non-functioning pituitary adenomas. The other pituitary tumors show a specific pattern of hormone secretion. About 25% to 41% of all pituitary tumors are prolactinomas, acromegaly with production of growth hormone represents 10% to 15% of adenomas, Cushing's disease with production of adrenocorticotropic hormone accounts for 10%, and other hormonal characteristics are less common. Transsphenoidal resection and total adenomectomy are desirable. Radiosurgery has enriched the surgical treatment options. Surgical treatment is the intervention of choice except for prolactinomas, where pharmaceutical treatment is recommended. Pharmaceutical treatment consists of dopamine agonists such as cabergoline and somatostatin analogues that include octreotide and pasireotide; retinoic acid is of theoretical interest while peroxisome proliferator-activated receptor-gamma-ligands are not clinically useful. In acromegaly, pegvisomant is a further treatment option. Temozolomide should be considered in aggressive pituitary tumors. In general, pharmaceutical options developed recently have extended the repertoire of treatment possibilities of pituitary tumors.

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Section: Recent Advancesmentioning

confidence: 99%

Advances in understanding pituitary tumors

2014

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“…[30] Various Neuronavigation techniques can make reoperation easier, faster, and safer. [31][32][33][34][35][36][37] Open low-fields intraoperative MRI, using contrast-soaked cottonoid packing in the tumor resection cavity, can be used to monitor the precise extent of tumor removal. [38] Integrating MR angiography into surgical neuronavigation provides superior visualization of the carotid arteries.…”

Section: Techniquementioning

confidence: 99%

“…[128] Multimodality therapy such as Gamma knife, stereotactic radiotherapy, medical management, apart from endoscopic surgery, could be required for optimal tumor control. [32,102,129,130] The octreotide long-acting release and lanreotide Autogel are used in acromegaly patients and were found to have similar efficacy for biochemical cure and tumor shrinkage as compared to surgery. [131]…”

Section: Endocrinological Outcomementioning

confidence: 99%

Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma

Yadav

Sachdev

Parihar

et al. 2012

Journal of Neurosciences in Rural Practice

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Endoscopic endonasal trans-sphenoid surgery (EETS) is increasingly used for pituitary lesions. Pre-operative CT and MRI scans and peroperative endoscopic visualization can provide useful anatomical information. EETS is indicated in sellar, suprasellar, intraventricular, retro-infundibular, and invasive tumors. Recurrent and residual lesions, pituitary apoplexy and empty sella syndrome can be managed by EETS. Modern neuronavigation techniques, ultrasonic aspirators, ultrasonic bone curette can add to the safety. The binostril approach provides a wider working area. High definition camera is much superior to three-chip camera. Most of the recent reports favor EETS in terms of safety, quality of life and tumor resection, hospital stay, better endocrinological, and visual outcome as compared to the microscopic technique. Nasal symptoms, blood loss, operating time are less in EETS. Various naso-septal flaps and other techniques of CSF leak repair could help reduce complications. Complications can be further reduced after achieving the learning curve, good understanding of limitations with proper patient selection. Use of neuronavigation, proper post-operative care of endocrine function, establishing pituitary center of excellence and more focused residency and endoscopic fellowship training could improve results. The faster and safe transition from microscopic to EETS can be done by the team concept of neurosurgeon/otolaryngologist, attending hands on cadaveric dissection, practice on models, and observation of live surgeries. Conversion to a microscopic or endoscopic-assisted approach may be required in selected patients. Multi-modality treatment could be required in giant and invasive tumors. EETS appears to be a better surgical option in most pituitary adenoma.

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“…Taking further potential sequelae such as visual deficits [12], cerebral radiation injury [13] and tumor induction [1,14] into consideration, the role of RT for benign lesions of the pituitary gland has repeatedly been challenged. Moreover, controversial data on when to irradiate (primary vs. postoperative vs. salvage), whom to irradiate (secreting vs. non-secreting) and how to irradiate (fractionated stereotactic RT vs. radiosurgery vs. intensity modulated RT) have occupied scientists, clinicians and patients [5,15-17]. Several authors have addressed short- and medium-term outcome in irradiated pituitary adenoma patients [18,19], however little data is available on long results and toxicity.…”

Section: Introductionmentioning

confidence: 99%

Long term toxicity and prognostic factors of radiation therapy for secreting and non-secreting pituitary adenomas

et al. 2013

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BackgroundRadiotherapy is controversially discussed in the management of benign disorders for fear of late sequelae such as tumor induction. This study was initiated to investigate long-term toxicity, treatment outcome and prognostic factors after radiotherapy (RT) in patients with pituitary adenomas.Methods92 patients with pituitary adenomas were included in this analysis. RT was conducted using either 3D conformal (16%) or fractionated stereotactic techniques (83%) in a postoperative adjuvant setting (16%), as second-line treatment for recurring tumors (78%) or as primary treatment (6%). Postoperatively, RT was offered to patients with residual tumor tissue or in case of locally extensive adenomas, in whom early recurrence was deemed likely. Patients were followed for a median time of 152.5 months, and analysed for overall and local progression-free survival (OS and LPFS). Multiple factors were analysed for prognostic impact. Patients were contacted with an institutional questionnaire about qualiy of life (QOL). Statistical analysis was performed using the log-rank test and the Kaplan-Meier method using a software tool (SPSS 19.0).ResultsMedian follow-up was 152.5 months. Before treatment, 2% of all patients were diagnosed with adenoma-related hypopituitarism. Following surgery, 68% suffered from new pituitary deficits. RT was associated with mild toxicity, including visual deficits (5.4%) and hypopituitarism (10.9%). In particular, no radiation-induced brain necrosis or malignancy was observed. QOL was reported to be stable or improved in 92% of all patients, and RT was perceived to not compromise but increase QOL in the vast majority of patients (95%). OS after RT was 93.3% and 61.0% at 120 and 240 months. LPFS following RT was 90.4 and 75.5% at 120 and 240 months. Early initiation of RT after surgery instead of reserving it for recurring adenomas predisposed for improved outcome.ConclusionsRT for pituitary adenomas is safe and and self-reported QOL is stable or improved by almost all patients. Hypopituitarism rates are low. Local control appears improved in patients irradiated postoperatively over those undergoing RT for previously resected recurrent tumors.

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Recent advances in pituitary tumor management

Abstract: The advances in trans-sphenoidal surgical approaches, navigation technological improvements and the current results of stereotactic radiosurgery are discussed.

Cited by 9 publications

References 137 publications

Advances in understanding pituitary tumors

Advances in understanding pituitary tumors

Endoscopic endonasal trans-sphenoid surgery of pituitary adenoma

Long term toxicity and prognostic factors of radiation therapy for secreting and non-secreting pituitary adenomas

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