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Pituitary tumours


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mainly deals with technical aspects of radiation in pituitary tumors

mainly deals with technical aspects of radiation in pituitary tumors

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  • 2. INTRODUCTION Pituitary or hypophysis cerebri is an endocrine gland situated in relation to the base of the brain It is called the Master of endocrine orchestra It produces a number of hormones which control the secretions of many other endocrine gland of the body
  • 3. ANATOMY The pituitary gland or hypophysis is an endocrinabout 15 mm in ant-post and 12 mm in supero inferior axis It weighs about 0.5 gm. The pituitary gland occupies a cavity of the sphenoid bone called sella turcica Roof is formed by diaphragm sellae The stalk of pituitary is attached above to the floor of third ventricle
  • 4. Anatomy(cont..)  Relations  Superiorly:Diaphragma sellae,optic chiasma,infundibular recess of 3rd ventricle  Inferiorly:Hypophyseal fossa and its venous channels  On each side :The cavernous sinus with its contentModified from Lechan RM. Neuroendocrinology of Pituitary Hormone Regulation. Endocrinology and Metabolism Clinics 16:475-501, 1987
  • 5.  The anterior and intermediate lobe arises from the Rathke’s pouch The posterior lobe or neurohypophysis arises from the downward pocketing of third ventricle. Posterior lobe releases hormones the Oxytocin and Vasopressin which are synthesised in the supraoptic and paraventricular nuclei in hypothalamus Anterior lobe releases hormones ACTH,TSH,GH,FSH,LH,Prolactin
  • 6. EPIDEMIOLOGY Pituitary neoplasm account for 10% to 15% of diagnosed primary intracranial neoplasm 3% -25% pituitary glands are identified by autopsy 10% of healthy population has pituitary abnormality detected by MRI Approximately 70% are endocrinologically active Incidence of macroadenomas is similar between males and females However clinical manifestations of microadenomas are more in women
  • 7. EPIDEMIOLOGY (Cont…) 70% of adenomas present between the ages 30 -50 yrs Women have high incidence of pituitary adenomas(15-44 yrs) Annual incidence ranges from 0.5 to 0.7/100,000 Etiology of most adenomas is unknown A genetic predisposition to develop adenomas has been described in MEN I syndrome Carney complex Isolated familial somatotropinomas(IFS)
  • 8. NATURAL HISTORY Usually has a long natural history with an insidious onset of symptoms Symptoms are usually present for years prior to diagnosis When small pituitary tumour tends to be smooth round tumours Macroadenomas are known for their local invasive properties Malignant behaviour with distant metastases is rare
  • 9. CLINICAL PRESENTATIONS The presenting symptoms may be due to Hormonal malfunction Due to local tumour growth and pressure effect Endocrine abnormalities may be a consequence of hyper or hypo secretion of pituitary hormones. Hypopituitarism Hyperpituitarism Cushings syndrome Hyperprolactinomas Hyperthyroidism Acromegaly
  • 10. HYPOPITUITARISM Growth hormone deficiency:Short stature(Dwarfism) Gonadotrophins deficiency:Infertility,decreased sexual functions,loss of secondary sexual characters,menstrual irregularities TSH deficiency :Hypothyroidism ACTH deficiency :Hypocortisolism Prolactin deficiency :Lactation failure Vasopressin deficiency :Diabetes insipidus
  • 11. HYPERPITUITARISM HYPERPROLACTINEMIA Most common cause of pituitary hormone hypersecretion Amennorhoea Galactorrhoea Infertility INCREASED GH Acromegaly in adults Frontal bossing Increased hand foot size Mandibular enlargement,Prognathism Large fleshy nose Proximal muscle wasting,carpal tunnel syndrome,macroglossia Gigantism in children
  • 12.  INCREASED ACTH Causes cushing syndrome Central obesity Plethoric moon facies Purple striae,increased bruisability Glucose intolerence Acne,hirsuitism Proximal muscle weakness Hypertension Amennorhoea,infertility
  • 13. FEATURES OF SELLAR MASS LESION PITUITARY Hypopituitarism OPTIC CHIASMA Bitemporal Hemianopia Superior temporal defect CAVERNOUS SINUS Ophthalmoplegia Ptosis Diplopia OTHERS Head ache Hydrocephalus Dementia
  • 14. DIAGNOSTIC WORKUP Detailed History and complete physical examination Confirmation of diagnosis Radiological Examination MRI-preferred modality better visualisation of soft tissue and vascular structure CT Scan Biopsy –In a case of non secreting lesion
  • 15.  STAGING WORKUP: Chest x ray USG Whole abdomen General condition: Complete blood count Kidney function tests liver function test Urine analysis
  • 16.  HORMONAL ANALYSIS Serum Prolactin level Growth hormone:basal growth hormone level IGF-I Glucose suppression,insulin tolerence ACTH Hypersecretion: Serum ACTH,Dexamethasone supression test 24 hrs urine for 17-hydroxy corticosteroids and free cortisol Gonadal function:FSH,LH,Esradiol,Testosterone Thyroid function test Adrenal function:basal plasma,urinary steroids cortisol response to insulin induced hypoglycaemia
  • 17. CLASSIFICATION OF PITUITARY TUMOURS ANATOMICAL SIZE Microadenoma(<10 mm) Macroadenoma(>10 mm) PHYSIOLOGICAL Ant pituitary1. Prolactin2. Growth hormone3. Adrenocorticotrophic hormone4. Leutinizing hormone5. Follicle stimulating hormone6. Thyroid stimulating hormone Post pituitary1. Oxytocin2. Vasopressin
  • 18. Classification(Cont…) ACCORDING TO CLINICAL SYMPTOMS Functional Non functionaL ACCORDING TO EXTENT OF EXPANSION OR EROSION OF SELLA Grade 0: Intrapituitary microadenoma with normal sellar appearance Grade I: Nml-sized sella with asymmetric floor Grade II: Enlarged sella with an intact floor Grade III: Localized erosion of sellar floor Grade IV: Diffuse destruction of floor
  • 19. Classification(Cont…) ACCORDING TO SUPRASELLAR EXTENSION Type A: Tumor bulges into the chiasmatic cistern Type B: Tumor reaches the floor of the 3rd ventricle Type C: Tumor is more voluminous with extension into the 3rd ventricle up to the foramen of Monro Type D: Tumor extends into temporal or frontal fossa
  • 20. PATHOLOGICAL CLASSIFICATIONS Ant Pituitary has 5 specific cell types Somatotrophs:produces growth hormone,acidophilic Lactotrophs:produces prolactin,acidophilic Corticotrophs:produces ACTH,MSH,basophilic Thyrotrophs:produces TSH,basophilic Gonadotrophs:FSH,LH,basophilic Post pituitary:pituicytes and non myelinated fibres
  • 21. MANAGEMENT Observation Surgery Radiotherapy
  • 22. OBSERVATION In asymptomatic non secreting microadenomas Small asymptomatic prolactinomas 2 -4 mm no testing required 5-9 mm MRI can be done once yearly Indications for intervention Tumour growth on imaging symptoms of hypersecretion development of visual field defects
  • 23. < 10 mm > 10 mm Evaluate for: Evaluate for • Hormonal Hypersecretion Hormonal • Hormonal Hyposecretion Hypersecretion • Visual Changes/defects Hormonal or VisualNormal Abnormalities No AbnormalitiesObserve Observe Treatment
  • 24. SURGERYINDICATIONS It is the first line treatment for most symptomatic pituitary tumours Useful when medical or radiotherapy fails When prompt relief from mass effect and hormone secretion is required Pituitary apoplexy
  • 25.  TYPES MICROSCOPIC TRANSSEPTAL TRANSSPHENOIDAL Current standard surgical procedure Safe procedure with mortality rate 0.5% Contraindications are sphenoid sinusitis,ectatic midline carotid arteries,lateral surpasellar extent
  • 26.  ENDOSCOPIC TRANSNASAL TRANSSPHENOIDAL Allows better visualisation of pituitary gland,ghyophyseal stalk,cavernous sinuses,optic nerve and suprasallar areas .TRANSCRANIAL Requires craniotomy and retraction of frontal lobes Used for large invasive tumours with significant suprasellar extension When transsphenoidal approach is contraindicated
  • 27. COMPLICATIONS OF SURGERY CSF rhinorrhoea Meningitis Haemorrhage Stroke Damage to pituitary Visual loss
  • 28. RADIOTHERAPY INDICATIONS1. Hypersecretion and mass effect due to large tumours2. Incomplete resection of tumour3. Progressive disease after surgery4. Recurrent tumours
  • 29. RADIOTHERAPY TECHNIQUES Conventional External Beam Radiotherapy Manual planning 2D Planning 3D CRT Fractionated Stereotactic Radiation Therapy Gammaknief Radiosurgery
  • 30. MANUAL AND 2D PLANNING Positioning Supine with neck flexed and head at 45 degrees Pituitary board can be used to achieve this Immobilisation done with thermoplastic mask VOLUME The entire pituitary gland with extensions and a margin of 1-1.5 cm
  • 31.  PORTALS Two parallel and opp lat fields and one anterior or vertex beam that enters above the eyes The centre of the pituitary is located at a point 2-2.5 anteriorly to tragus and 2-2.5 cm superiorly to that point Taking this point as centre a field of( 4*4)cm-(6*6) cm is marked ENERGY 4-10 Mev or Co 60 DOSE Nonfunctioning tumours 45-50.4 Gy@1.8 Gy/# Functional tumours 50.4-54 Gy
  • 32. 3D PLANNING Image based treatment planning using a 3D technique is the standard of care Defining the tumour volume MRI,CT as well as clinical and surgical findings should be used to define the tumour volume CT simulation assists in defining treatment volume GTV is the pituitary adenomas including any extention into adjacent anatomic regions CTV :GTV+5 mm in a clear defined tumour or entire sella and cavernous sinus with invasive tumours PTV:CTV+5mm
  • 33. FRACTIONATED STEREOTACTIC RADIOTHERAPY(FSRT) FSRT is characterised by improved patient localisation,tighter volume definition more conformal isodose distributions It has better safety profile and efficacy IMMOBILISATION Aim is to achieve a patient positioning error of less than 3mm by various means like Invasive halo ring Radiocamera bite block Non invasive Head frames
  • 34. Stereotactic(cont…) TARGET VOLUME DELINEATION GTV is designed with help of MRI and extent of cavernous sinus invasion should be included No additional margins is required for CTV PTV:CTV +2-3 mm margin TREATMENT PLANNING Depends on the delivery systems available Options include Multiple spherical shots Dynamic conformal arches Nonisocentric robotic delivery DOSE 50.4 Gy in 28#@1.8Gy/#
  • 35. STEREOTACTIC RADIOSURGERY Accepted treatment for smaller,radiologically well defined tumours located at a distance (3-5 mm) from optic apparatus Contraindicated if optic chiasma is closer than (3 -5)mmto the tumour Delivery systems include linear accelerator and gamma knife Head is fixed with an appropriate stereotactic head frame and a high resolution imaging study is obtained MRI used for gamma knief while ct scan for linear accelerator Gamma knife uses smallest collimators and maximum number of isocentres . The dose to optic chiasma is limited to <8-9 Gy DOSE Non functioning (12-20Gy) Functioning (15-30 Gy)
  • 36. RESULTSMODALITY SURGERY SURG+POST GAMMA KNIEF VS OP RT RADIOSURGERY SURG+POSTO VS P RT RT ALONERESULTS Park Grigsby et al al 10 yrs Proggression Tumour control at recurrence rate free survival at 5 5 yrs is 93.6% and 2.3%with yrs 96% and 20 endocrinological rt,50.5%only yrs 88% improvement is surgery 80.3%CONCLUSION Post op RT Surg+rt had a Results are similar should be greater control to #EBRT but preffered of local disease gamma knief seems to be safer in terms of complications
  • 37. COMPLICATIONS OF RADIOTHERAPY ACUTE REACTIONS1. Fatigue2. Focal alopecia3. Otitis CHRONIC REACTIONS1. Hypopituitarism2. Damage to optic apparatus3. Secondary brain tumours4. Brain necrosis
  • 38. CONCLUSION Pituitary tumors are slow growing tumours. Surgery is the first choice of treatment Radiation is generally used as an adjuvant or salvage therapy Surgery followed by post op radiation produce better results Newer treatment modalities like gamma knife produce less complications
  • 39. THANKYOU