Pituitary Adenomas Chien Wei OMS IV September 14, 2006
Overview <ul><li>Background </li></ul><ul><li>Clinical Presentation </li></ul><ul><li>Classification </li></ul><ul><li>Is ...
Anatomy <ul><li>60 mg midline structure in sella turcica </li></ul><ul><li>Bordered by diaphragma sellae, tuberculum sella...
 
 
Function <ul><li>Anterior Lobe: </li></ul><ul><ul><li>FSH </li></ul></ul><ul><ul><li>LH </li></ul></ul><ul><ul><li>ACTH </...
Epidemiology <ul><li>Etiology is unknown </li></ul><ul><li>Not associated with environmental factors </li></ul><ul><li>10-...
Natural History <ul><li>Pituitary adenomas have long natural history </li></ul><ul><li>Vary in size and direction of sprea...
Clinical Presentation <ul><li>Most common are endocrine abnormalities – hyper-/hyposecretion of ant. pituitary hormones </...
Endocrine-Active Pituitary Adenomas <ul><li>Prolactin – Amenorrhea, galactorrhea, impotence </li></ul><ul><li>Growth hormo...
Non-functioning Adenomas <ul><li>25-30 % of patients do not have classical hypersecretory syndromes </li></ul><ul><li>May ...
Evaluation <ul><li>MRI </li></ul><ul><li>Visual field assessment </li></ul><ul><li>Endocrine evaluation </li></ul><ul><ul>...
Classifying  <ul><li>Imaging/surgical classification </li></ul><ul><li>Clinical/endocrine – functional vs. nonfunctional <...
Classification <ul><li>Microadenomas – Grades 0 and I </li></ul><ul><li>Macroadenomas – Grades II to IV </li></ul><ul><li>...
Classification <ul><li>Type A: Tumor bulges into the chiasmatic cistern </li></ul><ul><li>Type B: Tumor reaches the floor ...
Pathologic Classification <ul><li>Benign or malignant </li></ul><ul><li>Chromophobic – Non-functioning </li></ul><ul><li>B...
WHO Classification <ul><li>Five-tiered system </li></ul><ul><ul><li>Clinical presentation and secretory activity </li></ul...
The long-term efficacy of conservative surgery and radiotherapy in the control of pituitary adenomas <ul><li>Retrospective...
Method <ul><li>252 of 411 pts with non-functioning pituitary adenomas  </li></ul><ul><li>131 of 411 pts had functional pit...
Radiation Therapy <ul><li>Post-op RT to prescribed dose of 45-50 Gy in 25-30 fxs delivered at  ≤ 1.8Gy/fx </li></ul><ul><l...
Results M. Brada et al, Clinical Endocrinology (1993) 38, 571-578 88% 20 94% 10 96% 5 Progression free survival Years afte...
Results <ul><li>Extent of surgical resection did not correlate with outcome </li></ul><ul><li>Relative risk of death compa...
Conclusions <ul><li>High tumor control rate and low toxicity in nonfunctional pituitary adenomas suggests that limited sur...
Results of surgery and irradiation or irradiation alone for pituitary adenomas <ul><li>Retrospective review of all patient...
Methods <ul><li>212 patients with pituitary adenoma underwent treatment between 1954 and 1982 </li></ul><ul><li>Median f/u...
Radiation Therapy Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988) 175 18-25 MV X-rays 13 4 MV X-rays 8 Cobalt 60 12 O...
Radiation Therapy <ul><li>Most patients treated with parallel-opposed portals </li></ul><ul><li>Mean field sizes: 32.1 cm2...
Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988)
Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988)
Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988)
Conclusion <ul><li>Overall survival after treatment for all patients is not significantly different from an age, sex, and ...
Gamma-Knife Radiosurgery
Gamma knife radiosurgery for pituitary adenomas <ul><li>Retrospective review of 79 pts treated with GKS for pituitary aden...
Methods <ul><li>79 of 108 pts treated between 1993 to 1999 with GKS whom f/u exceeded 6 mo. </li></ul><ul><li>56 FAs ( 29 ...
Radiosurgical Treatment <ul><li>40 pts (24 FAs and 16 NFAs) underwent pre-GKS surgical resection </li></ul><ul><li>Mean ma...
Results <ul><li>Tumor control – 93.6% (NFA 95.6%, FA 92.8%) </li></ul><ul><li>Tumor shrinkage – 24.1% (NFA 26.1%, FA 23.2%...
Conclusion <ul><li>Tumor growth control results achieved with GKS is similar to those for fractionated RT </li></ul><ul><l...
Pituitary Adenoma: The efficacy of RT as the sole treatment <ul><li>Retrospective study of 29 patients with nonfunctional ...
General Management <ul><li>Pituitary adenoma management is complex and is dictated by size, symptoms, and character of tum...
General Management <ul><li>Multidisciplinary approach </li></ul><ul><li>Goals: </li></ul><ul><ul><li>Define tumor extent <...
General Management <ul><li>Microadenomas: transsphenoidal surgery or RT </li></ul><ul><li>Macoradenomas: initial surgery w...
Pre-treatment MRI Close to  Chiasm? yes no Surgery EBRT SRS/gamma-knife Visual field testing Deficit yes no Surgery Surger...
Appropriate for GKS
Contraindication for GKS
RT Dosing Guidelines 33-95% 90-95% 25-30 Gy to margin 45-54 Gy Functioning tumors NA 95% 12-24 Gy to margin 45-50.4 Gy Non...
Complications <ul><li>Hypopituitarism </li></ul><ul><li>Vision loss </li></ul><ul><li>Carcinogenic </li></ul><ul><li>Radia...
Future Directions <ul><li>Profiles of toxicity in the 2-D vs. 3-D era </li></ul>
Thank You <ul><li>Faculty </li></ul><ul><li>Residents </li></ul>
Upcoming SlideShare
Loading in …5
×

Pituitary Adenomas

1,597
-1

Published on

Published in: Health & Medicine
0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,597
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
161
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

Pituitary Adenomas

  1. 1. Pituitary Adenomas Chien Wei OMS IV September 14, 2006
  2. 2. Overview <ul><li>Background </li></ul><ul><li>Clinical Presentation </li></ul><ul><li>Classification </li></ul><ul><li>Is it beneficial to give RT after transsphenoidal resection </li></ul><ul><li>How much time post-RT should pt. be followed? </li></ul><ul><li>Is there benefit to GKS? </li></ul><ul><li>General Management </li></ul><ul><li>Complications </li></ul>
  3. 3. Anatomy <ul><li>60 mg midline structure in sella turcica </li></ul><ul><li>Bordered by diaphragma sellae, tuberculum sellae, dorsum sellae, lateral sinuses, and sphenoid sinuses </li></ul><ul><li>Anterior and posterior lobes </li></ul>
  4. 6. Function <ul><li>Anterior Lobe: </li></ul><ul><ul><li>FSH </li></ul></ul><ul><ul><li>LH </li></ul></ul><ul><ul><li>ACTH </li></ul></ul><ul><ul><li>TSH </li></ul></ul><ul><ul><li>Prolactin </li></ul></ul><ul><ul><li>GH </li></ul></ul><ul><li>Posterior Lobe: </li></ul><ul><ul><li>ADH </li></ul></ul><ul><ul><li>Oxytocin </li></ul></ul>
  5. 7. Epidemiology <ul><li>Etiology is unknown </li></ul><ul><li>Not associated with environmental factors </li></ul><ul><li>10-15% of all primary brain tumors </li></ul><ul><li>20-25% of pituitary glands at autopsy found to have adenomas </li></ul><ul><li>70% of adenomas are endocrinogically secreting </li></ul><ul><li>25% of those with MEN-I develop pituitary adenomas </li></ul>
  6. 8. Natural History <ul><li>Pituitary adenomas have long natural history </li></ul><ul><li>Vary in size and direction of spread </li></ul><ul><li>Microadenomas < 10 mm – may cause focal bulging </li></ul><ul><li>Macroadenomas > 10 mm – cause problems due to mass effect </li></ul>
  7. 9. Clinical Presentation <ul><li>Most common are endocrine abnormalities – hyper-/hyposecretion of ant. pituitary hormones </li></ul><ul><li>HA </li></ul><ul><li>Vision changes – bitemporal hemianopsia and superior </li></ul><ul><li>temporal defects </li></ul>
  8. 10. Endocrine-Active Pituitary Adenomas <ul><li>Prolactin – Amenorrhea, galactorrhea, impotence </li></ul><ul><li>Growth hormone – Gigantism and acromegaly </li></ul><ul><li>Corticotropin – Cushing’s disease, Nelson’s syndrome post adrenalectomy </li></ul><ul><li>TSH - Hyperthyroidism </li></ul>
  9. 11. Non-functioning Adenomas <ul><li>25-30 % of patients do not have classical hypersecretory syndromes </li></ul><ul><li>May grow to a large size before they are detected </li></ul><ul><li>Present due to mass effect </li></ul><ul><ul><li>Visual deficits </li></ul></ul><ul><ul><li>HA </li></ul></ul><ul><ul><li>Hormone deficiency </li></ul></ul>
  10. 12. Evaluation <ul><li>MRI </li></ul><ul><li>Visual field assessment </li></ul><ul><li>Endocrine evaluation </li></ul><ul><ul><li>Tests of normal gonadal, thyroid, and adrenal function </li></ul></ul><ul><ul><li>Radioimmunoassays – for hormone levels </li></ul></ul>
  11. 13. Classifying <ul><li>Imaging/surgical classification </li></ul><ul><li>Clinical/endocrine – functional vs. nonfunctional </li></ul><ul><li>Pathological classification </li></ul><ul><li>WHO classification – reconciles the three systems above </li></ul>
  12. 14. Classification <ul><li>Microadenomas – Grades 0 and I </li></ul><ul><li>Macroadenomas – Grades II to IV </li></ul><ul><li>Grade 0: Intrapituitary microadenoma with normal sellar appearance </li></ul><ul><li>Grade I: Nml-sized sella with asymmetric floor </li></ul><ul><li>Grade II: Enlarged sella with an intact floor </li></ul><ul><li>Grade III: Localized erosion of sellar floor </li></ul><ul><li>Grade IV: Diffuse destruction of floor </li></ul>
  13. 15. Classification <ul><li>Type A: Tumor bulges into the chiasmatic cistern </li></ul><ul><li>Type B: Tumor reaches the floor of the 3 rd ventricle </li></ul><ul><li>Type C: Tumor is more voluminous with extension into the 3 rd ventricle up to the foramen of Monro </li></ul><ul><li>Type D: Tumor extends into temporal or frontal fossa </li></ul>
  14. 16. Pathologic Classification <ul><li>Benign or malignant </li></ul><ul><li>Chromophobic – Non-functioning </li></ul><ul><li>Basophilic – Cushing’s </li></ul><ul><li>Acidophilic - Acromegaly </li></ul><ul><li>Mixed </li></ul>
  15. 17. WHO Classification <ul><li>Five-tiered system </li></ul><ul><ul><li>Clinical presentation and secretory activity </li></ul></ul><ul><ul><li>Size and invasiveness (e.g. Hardy) </li></ul></ul><ul><ul><li>Histology (typical vs. atypical) </li></ul></ul><ul><ul><li>Immunohistologic profile </li></ul></ul><ul><ul><li>Ultrasturctural subtype </li></ul></ul>
  16. 18. The long-term efficacy of conservative surgery and radiotherapy in the control of pituitary adenomas <ul><li>Retrospective study of 411 patients treated with EBRT for pituitary adenomas </li></ul><ul><li>Goal is to assess both long-term efficacy and toxicity of conservative surgery and RT in the management of pituitary adenomas </li></ul>M. Brada et al, Clinical Endocrinology (1993) 38, 571-578
  17. 19. Method <ul><li>252 of 411 pts with non-functioning pituitary adenomas </li></ul><ul><li>131 of 411 pts had functional pituitary adenomas (62 acromegaly, 60 prolactinomas, 7 Cushing’s, 1 TSH, 1 Gn secreting) </li></ul><ul><li>338 had surgical intervention; 11 with complete resection </li></ul><ul><li>187 transfrontal approach, 24 trans-sphenoidal approach, 35 had no surgery </li></ul><ul><li>Median f/u of 10.5 yrs </li></ul>M. Brada et al, Clinical Endocrinology (1993) 38, 571-578
  18. 20. Radiation Therapy <ul><li>Post-op RT to prescribed dose of 45-50 Gy in 25-30 fxs delivered at ≤ 1.8Gy/fx </li></ul><ul><li>Three-field technique aimed at a target volume encompassing the tumor and a 1-2cm margin </li></ul><ul><li>Patient treated in supine position </li></ul>M. Brada et al, Clinical Endocrinology (1993) 38, 571-578
  19. 21. Results M. Brada et al, Clinical Endocrinology (1993) 38, 571-578 88% 20 94% 10 96% 5 Progression free survival Years after RT
  20. 22. Results <ul><li>Extent of surgical resection did not correlate with outcome </li></ul><ul><li>Relative risk of death compared with normal population was 1.76 (p<0.001) </li></ul><ul><li>No prognostic factors for survival were identified </li></ul><ul><li>Morbidity of RT was low </li></ul><ul><li>1.5% of pts had assumed radiation induced visual deterioration </li></ul><ul><li>Cumulative risk for 2 nd brain tumor at 20 yrs was 1.9% </li></ul>M. Brada et al, Clinical Endocrinology (1993) 38, 571-578
  21. 23. Conclusions <ul><li>High tumor control rate and low toxicity in nonfunctional pituitary adenomas suggests that limited surgical approach and post-surgical conventional fractionated EBRT should be the treatment of choice </li></ul>M. Brada et al, Clinical Endocrinology (1993) 38, 571-578
  22. 24. Results of surgery and irradiation or irradiation alone for pituitary adenomas <ul><li>Retrospective review of all patients with pituitary adenoma treated with RT alone, surgery and RT, or RT following surgical failure </li></ul>Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988)
  23. 25. Methods <ul><li>212 patients with pituitary adenoma underwent treatment between 1954 and 1982 </li></ul><ul><li>Median f/u was 11.9 yrs </li></ul><ul><li>Radiologic evaluation consisted of skull films, angiography, pneumoenchephalography, ventriculgraphy, CT and MRI </li></ul><ul><li>73% had transfrontal approach </li></ul>Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988)
  24. 26. Radiation Therapy Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988) 175 18-25 MV X-rays 13 4 MV X-rays 8 Cobalt 60 12 Orthovoltage X-rays Number of Patients RT
  25. 27. Radiation Therapy <ul><li>Most patients treated with parallel-opposed portals </li></ul><ul><li>Mean field sizes: 32.1 cm2 for EBRT alone, 45.3 cm2 for surgery and EBRT, and 40.3 cm2 for EBRT for surgical failures </li></ul><ul><li>Median dose for all patients is 4967 cGy </li></ul><ul><li>Pts receiving EBRT only had a mean dose of 3989 cGy; post-op EBRT 4493 cGy, and 4553 for EBRT salvage of surgical failures </li></ul>Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988)
  26. 28. Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988)
  27. 29. Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988)
  28. 30. Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988)
  29. 31. Conclusion <ul><li>Overall survival after treatment for all patients is not significantly different from an age, sex, and race matched population </li></ul><ul><li>Patients receiving surgery and post-op RT had a greater control of local disease </li></ul><ul><li>EBRT salvage of surgical failures is possible </li></ul><ul><li>EBRT treatment results in a low complication rate </li></ul>Grigsby et al, J of Neuro-Oncology 6: 129-134 (1988)
  30. 32. Gamma-Knife Radiosurgery
  31. 33. Gamma knife radiosurgery for pituitary adenomas <ul><li>Retrospective review of 79 pts treated with GKS for pituitary adenomas </li></ul><ul><li>Purpose: To look at the clinical results of GKS and both its efficacy and safety in treatment of pituitary adenomas </li></ul>Masahiro et al, J of Neurosurgery (Suppl 3) 93:19-22,2000
  32. 34. Methods <ul><li>79 of 108 pts treated between 1993 to 1999 with GKS whom f/u exceeded 6 mo. </li></ul><ul><li>56 FAs ( 29 acromegaly, 15 prolactinomas, 12 Cushing’s) and 23 NFAs </li></ul><ul><li>Mean age 50.2 yrs (26 y/o – 82 y/o) </li></ul><ul><li>49 female and 30 male </li></ul><ul><li>Mean tumor vol. 7.1 cm3 </li></ul>Masahiro et al, J of Neurosurgery (Suppl 3) 93:19-22,2000
  33. 35. Radiosurgical Treatment <ul><li>40 pts (24 FAs and 16 NFAs) underwent pre-GKS surgical resection </li></ul><ul><li>Mean margin dose – 22.5 Gy (FA 24.2 Gy, NFA 19.5) </li></ul><ul><li>Highest possible isodose (50-70%) used </li></ul><ul><li>Mean f/u period of 26.4 months </li></ul><ul><li>Tumor control= decreasing or unchanged tumor vol. </li></ul><ul><li>Endocrinologic improvement=fall in elev. hormone level </li></ul>Masahiro et al, J of Neurosurgery (Suppl 3) 93:19-22,2000
  34. 36. Results <ul><li>Tumor control – 93.6% (NFA 95.6%, FA 92.8%) </li></ul><ul><li>Tumor shrinkage – 24.1% (NFA 26.1%, FA 23.2%) </li></ul><ul><li>Endocrinological improvement – 80.3% </li></ul><ul><li>Endocrinological normalization – 30.3% </li></ul><ul><li>5/6 pts with preexisting visual field showed improvement </li></ul><ul><li>3 pts. developed complications </li></ul>Masahiro et al, J of Neurosurgery (Suppl 3) 93:19-22,2000
  35. 37. Conclusion <ul><li>Tumor growth control results achieved with GKS is similar to those for fractionated RT </li></ul><ul><li>GKS may produce better results than conventional RT in tx of pituitary adenoma produced endocrinopathies </li></ul><ul><li>GKS seems to be safer than fractionated RT in terms of complications </li></ul>Masahiro et al, J of Neurosurgery (Suppl 3) 93:19-22,2000
  36. 38. Pituitary Adenoma: The efficacy of RT as the sole treatment <ul><li>Retrospective study of 29 patients with nonfunctional or prolactin secreting macroadenomas </li></ul><ul><li>Tumor dose – 4500 cGy in 4-5 wks </li></ul><ul><li>Tumor controlled in 93% of pts </li></ul><ul><li>Conclusion: RT is effective for improving vision and can normalize hyperprolactinemia </li></ul><ul><li>Doses need not exceed 4500 cGy in 25 fxs </li></ul>Rush SC, Newall J., Int J Radiat Oncol Biol Phys 1989; 17:165
  37. 39. General Management <ul><li>Pituitary adenoma management is complex and is dictated by size, symptoms, and character of tumor </li></ul><ul><li>Treatment options require multiple modalities, including: Surgery, RT, SRS, and medical management </li></ul>
  38. 40. General Management <ul><li>Multidisciplinary approach </li></ul><ul><li>Goals: </li></ul><ul><ul><li>Define tumor extent </li></ul></ul><ul><ul><li>Evaluate hormone activity </li></ul></ul><ul><ul><li>Remove tumor mass </li></ul></ul><ul><ul><li>Control hypersecretion </li></ul></ul><ul><ul><li>Correct endocrine deficiencies </li></ul></ul>
  39. 41. General Management <ul><li>Microadenomas: transsphenoidal surgery or RT </li></ul><ul><li>Macoradenomas: initial surgery with post-op RT </li></ul><ul><li>Medical Management </li></ul><ul><ul><li>Bromocriptine </li></ul></ul><ul><ul><li>Somatostatin </li></ul></ul>
  40. 42. Pre-treatment MRI Close to Chiasm? yes no Surgery EBRT SRS/gamma-knife Visual field testing Deficit yes no Surgery Surgery EBRT Treatment Algorithm
  41. 43. Appropriate for GKS
  42. 44. Contraindication for GKS
  43. 45. RT Dosing Guidelines 33-95% 90-95% 25-30 Gy to margin 45-54 Gy Functioning tumors NA 95% 12-24 Gy to margin 45-50.4 Gy Nonfunctioning tumors Biochemical Control Local Tumor Control Radio-surgery (optic chiasm dose < 9 Gy) EBRT (1.8Gy/fx)
  44. 46. Complications <ul><li>Hypopituitarism </li></ul><ul><li>Vision loss </li></ul><ul><li>Carcinogenic </li></ul><ul><li>Radiation necrosis </li></ul><ul><li>Cerebral Infarction </li></ul>
  45. 47. Future Directions <ul><li>Profiles of toxicity in the 2-D vs. 3-D era </li></ul>
  46. 48. Thank You <ul><li>Faculty </li></ul><ul><li>Residents </li></ul>
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×