Debulking surgery of pituitary adenoma as a strategy to facilitate definitive stereotactic radiosurgery

  • Neil Forster
  • Ronald Warnick
  • Vinita Takiar
  • Luke Pater
  • John Breneman
Clinical Study

Abstract

In patients with pituitary adenomas (PA) who are unable to undergo complete surgical resection, radiation therapy (RT), specifically stereotactic radiosurgery (SRS), results in excellent local control. However, the utility of radiosurgery may be limited by the proximity of the lesion to the optic chiasm (OC). We evaluate the efficacy of debulking surgery in increasing the PA-OC separation to convert patients into SRS candidates. From 2007 to 2015, 31 patients with PA < 2 mm from the OC underwent debulking surgery followed by RT within 2 years of resection. Coronal and sagittal T1-pre- and post-contrast sequences were used to determine PA-OC separation. Time interval between postoperative and pre-radiotherapy MRI scans and type of radiation therapy were analyzed. Functional tumor status, tumor characteristics [cavernous sinus (CS) or suprasellar (SS) involvement, chiasm/nerve encasement (NE)], and presence of ≥ 2 of these characteristics (multiple factors, MF) was also noted. Surgery converted 9 of 31 patients (29%) to SRS candidates. Median time from surgery to pre-RT planning MRI was 8 months (range 2–20). Of the 31 patients initially ineligible for SRS, 6 became eligible immediately after surgery, and another 3 were deemed eligible on follow-up. Mean PA-OC separation was 0.3 mm preoperative, 1.4 mm postoperative, and 2.1 mm at time of SRS (p = 0.002). Preoperative SS, NE, and MF involvement predicted pre-RT separation < 2 mm. Debulking surgery of unresectable pituitary tumors is a successful strategy for converting select radiosurgery-ineligible patients to radiosurgery candidates. Absence of preoperative SS, NE, and MF predicts for successful conversion.

Keywords

Debulking surgery Radiosurgery Pituitary adenoma Optic chiasm 

Notes

Compliance with ethical standards

Conflict of interest

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

References

  1. 1.
    Pamir MN, Kiliç T, Belirgen M, Abacioglu U, Karabekiroglu N (2007) Pituitary adenomas treated with gamma knife radiosurgery: Volumetric analysis of 100 cases with minimum 3 year follow-up. Neurosurgery 61:270 – 80CrossRefPubMedGoogle Scholar
  2. 2.
    Brada M, Rajan B, Traish D et al (1993) The long-term efficacy of conservative surgery and radiotherapy in the control of pituitary adenomas. Clinical Endocrinol 38:571–578CrossRefGoogle Scholar
  3. 3.
    Alameda C, Lucas T, Pineda E et al (2005) Experience in management of 51 non-functioning pituitary adenomas: indications for post-operative radiotherapy. J Endocrinol Investig 28:18–22CrossRefGoogle Scholar
  4. 4.
    Park P, Chandler WF, Barkan AL et al (2004) The role of radiation therapy after surgical resection of nonfunctional pituitary macroadenomas. Neurosurgery 55:100–107CrossRefPubMedGoogle Scholar
  5. 5.
    van den Bergh AC, Van den Berg G, Schoorl MA et al (2007) Immediate postoperative radiotherapy in residual nonfunctioning pituitary adenoma: beneficial effect on local control without additional negative impact on pituitary function and life expectancy. Int J Radiat Oncol Biol Phys 67:863–869CrossRefPubMedGoogle Scholar
  6. 6.
    Castinetti F, Nagai M, Morange I et al (2009) Long-term results of stereotactic radiosurgery in secretory pituitary adenomas. J Clin Endocrinol Metab 94:3400–3407CrossRefPubMedGoogle Scholar
  7. 7.
    Sheehan JP, Niranjan A, Sheehan JM et al (2005) Stereotactic radiosurgery for pituitary adenomas: an intermediate review of its safety, efficacy, and role in the neurosurgical treatment armamentarium. J Neurosurg 102:678–691CrossRefPubMedGoogle Scholar
  8. 8.
    Minniti G, Gilbert D, Brada M (2009) Modern techniques for pituitary radiotherapy. Rev Endocr Metab Disord 10:135–144CrossRefPubMedGoogle Scholar
  9. 9.
    Leavitt JA, Stafford SL, Link MJ, Pollock BE (2013) Long-term evaluation of radiation-induced optic neuropathy after single-fraction stereotactic radiosurgery. Int J Radiat Oncol Biol Phys 87:524–527CrossRefPubMedGoogle Scholar
  10. 10.
    Fisher C, Batke J (2013) Editorial: separation surgery. J Neurosurg Spine 18:205–206; discussion p 6CrossRefPubMedGoogle Scholar
  11. 11.
    Laufer I, Iorgulescu JB, Chapman T et al (2013) Local disease control for spinal metastases following “separation surgery” and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients. J Neurosurg Spine 18:207–214CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Moulding HD, Elder JB, Lis E et al (2010) Local disease control after decompressive surgery and adjuvant high-dose single-fraction radiosurgery for spine metastases. J Neurosurg Spine 13:87–93CrossRefPubMedGoogle Scholar
  13. 13.
    Zierhut D, Flentje M, Adolph J, Erdmann J, Raue F, Wannenmacher M (1995) External radiotherapy of pituitary adenomas. Int J Radiat Oncol Biol Phys 33:307–314CrossRefPubMedGoogle Scholar
  14. 14.
    McCord MW, Buatti JM, Fennell EM et al (1997) Radiotherapy for pituitary adenoma: long-term outcome and sequelae. Int J Radiat Oncol Biol Phys 39:437–444CrossRefPubMedGoogle Scholar
  15. 15.
    Kim JW, Kim DG (2014) Stereotactic radiosurgery for functioning pituitary adenomas. World Neurosurg 82:58–59CrossRefPubMedGoogle Scholar
  16. 16.
    Laws ER, Sheehan JP, Sheehan JM, Jagnathan J, Jane JA Jr, Oskouian R (2004) Stereotactic radiosurgery for pituitary adenomas: a review of the literature. J Neuro 69:257–272Google Scholar
  17. 17.
    Greenman Y, Ouaknine G, Veshchev I, Reider-Groswasser I, Segev Y, Stern N (2003) Postoperative surveillance of clinically nonfunctioning pituitary macroadenomas: markers of tumour quiescence and regrowth. Clin Endocrinol 58:763–769CrossRefGoogle Scholar
  18. 18.
    Mitsumori M, Shrieve DC, Alexander E, 3rd, et al (1998) Initial clinical results of LINAC-based stereotactic radiosurgery and stereotactic radiotherapy for pituitary adenomas. Int J Radiat Oncol Biol Phys 42:573–580CrossRefPubMedGoogle Scholar
  19. 19.
    Fu P, He Y-s, Cen Y-c et al (2016) Microneurosurgery and subsequent gamma knife radiosurgery for functioning pituitary macroadenomas or giant adenomas: one institution’s experience. Clin Neurol Neurosurg 145:8–13CrossRefPubMedGoogle Scholar
  20. 20.
    Pomeraniec IJ, Dallapiazza RF, Xu Z, Jane JA Jr, Sheehan JP. Early versus late Gamma Knife radiosurgery following transsphenoidal resection for nonfunctioning pituitary macroadenomas: a matched cohort study. J Neurosurg 2015:1–11Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Radiation OncologyUniversity of CincinnatiCincinnatiUSA
  2. 2.Department of NeurosurgeryUC Neuroscience InstituteCincinnatiUSA

Personalised recommendations