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PRESENTED BY :Dr SANDIP KUMAR BARIK              DEPT OF RADIOTHERAPYMODERATOR: Dr RAJENDRA KUMAR
INTRODUCTION Pituitary or hypophysis cerebri is an endocrine gland situated in  relation to the base of the brain It is ...
ANATOMY The pituitary gland or hypophysis is  an endocrinabout 15 mm in ant-post  and 12 mm in supero inferior axis It w...
Anatomy(cont..)     Relations     Superiorly:Diaphragma          sellae,optic          chiasma,infundibular recess of   ...
 The anterior and intermediate  lobe arises from the Rathke’s  pouch The posterior lobe or  neurohypophysis arises from ...
EPIDEMIOLOGY Pituitary neoplasm account for 10% to 15% of diagnosed primary  intracranial neoplasm 3% -25% pituitary gla...
EPIDEMIOLOGY (Cont…) 70% of adenomas present between the ages 30 -50 yrs Women have high incidence of pituitary adenomas...
NATURAL HISTORY Usually has a long natural history with an insidious onset of symptoms Symptoms are usually present for ...
CLINICAL PRESENTATIONS The presenting symptoms may be due to        Hormonal malfunction        Due to local tumour growt...
HYPOPITUITARISM Growth hormone deficiency:Short stature(Dwarfism) Gonadotrophins deficiency:Infertility,decreased sexual...
HYPERPITUITARISM HYPERPROLACTINEMIA   Most common cause of pituitary hormone hypersecretion   Amennorhoea   Galactorrh...
 INCREASED ACTH Causes cushing syndrome Central obesity Plethoric moon facies Purple striae,increased bruisability G...
FEATURES OF SELLAR MASS LESION PITUITARY Hypopituitarism OPTIC CHIASMA Bitemporal Hemianopia Superior temporal defect...
DIAGNOSTIC WORKUP Detailed History and complete physical examination Confirmation of diagnosis Radiological Examination...
 STAGING WORKUP: Chest x ray                       USG Whole abdomen General condition:       Complete blood count      ...
 HORMONAL ANALYSIS Serum Prolactin level Growth hormone:basal growth hormone level                   IGF-I             ...
CLASSIFICATION OF PITUITARY TUMOURS ANATOMICAL SIZE Microadenoma(<10 mm) Macroadenoma(>10 mm) PHYSIOLOGICAL Ant pitui...
Classification(Cont…) ACCORDING TO CLINICAL SYMPTOMS Functional Non functionaL ACCORDING TO EXTENT OF EXPANSION OR ERO...
Classification(Cont…) ACCORDING TO SUPRASELLAR EXTENSION Type A: Tumor bulges into the chiasmatic cistern Type B: Tumor...
PATHOLOGICAL CLASSIFICATIONS Ant Pituitary has 5 specific cell  types Somatotrophs:produces growth  hormone,acidophilic...
MANAGEMENT Observation Surgery Radiotherapy
OBSERVATION In asymptomatic non secreting microadenomas Small asymptomatic prolactinomas        2 -4 mm no testing requi...
< 10 mm                                      > 10 mm                                                       Evaluate for:  ...
SURGERYINDICATIONS It is the first line treatment for most symptomatic pituitary tumours   Useful when medical or radiot...
 TYPES MICROSCOPIC TRANSSEPTAL TRANSSPHENOIDAL   Current standard surgical procedure   Safe procedure with mortality r...
   ENDOSCOPIC TRANSNASAL    TRANSSPHENOIDAL   Allows better visualisation of    pituitary gland,ghyophyseal    stalk,cav...
COMPLICATIONS OF SURGERY CSF rhinorrhoea Meningitis Haemorrhage Stroke Damage to pituitary Visual loss
RADIOTHERAPY INDICATIONS1.   Hypersecretion and mass effect due to large tumours2.   Incomplete resection of tumour3.   P...
RADIOTHERAPY TECHNIQUES   Conventional External Beam Radiotherapy   Manual planning   2D Planning   3D CRT   Fractio...
MANUAL AND 2D PLANNING Positioning Supine with neck flexed and head at  45 degrees Pituitary board can be used to  achi...
 PORTALS Two parallel and opp lat fields and one anterior or vertex beam that  enters above the eyes The centre of the ...
3D PLANNING Image based treatment planning using    a 3D technique is the standard of care Defining the tumour volume M...
FRACTIONATED STEREOTACTIC RADIOTHERAPY(FSRT) FSRT is characterised by improved patient localisation,tighter volume  defin...
Stereotactic(cont…) TARGET VOLUME DELINEATION GTV is designed with help of MRI and extent of cavernous sinus    invasion...
STEREOTACTIC RADIOSURGERY Accepted treatment for smaller,radiologically well defined tumours located  at a distance (3-5 ...
RESULTSMODALITY     SURGERY           SURG+POST            GAMMA KNIEF                VS             OP RT                ...
COMPLICATIONS OF RADIOTHERAPY ACUTE REACTIONS1.   Fatigue2.   Focal alopecia3.   Otitis    CHRONIC REACTIONS1.   Hypopit...
CONCLUSION Pituitary tumors are slow growing tumours. Surgery is the first choice of treatment Radiation is generally u...
THANKYOU
Pituitary tumours
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Pituitary tumours

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mainly deals with technical aspects of radiation in pituitary tumors

Pituitary tumours

  1. 1. PRESENTED BY :Dr SANDIP KUMAR BARIK DEPT OF RADIOTHERAPYMODERATOR: Dr RAJENDRA KUMAR
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 15.  STAGING WORKUP: Chest x ray USG Whole abdomen General condition: Complete blood count Kidney function tests liver function test Urine analysis
  16. 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. 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. 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. 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. 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. 21. MANAGEMENT Observation Surgery Radiotherapy
  22. 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. 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. 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. 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. 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. 27. COMPLICATIONS OF SURGERY CSF rhinorrhoea Meningitis Haemorrhage Stroke Damage to pituitary Visual loss
  28. 28. RADIOTHERAPY INDICATIONS1. Hypersecretion and mass effect due to large tumours2. Incomplete resection of tumour3. Progressive disease after surgery4. Recurrent tumours
  29. 29. RADIOTHERAPY TECHNIQUES Conventional External Beam Radiotherapy Manual planning 2D Planning 3D CRT Fractionated Stereotactic Radiation Therapy Gammaknief Radiosurgery
  30. 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. 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. 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. 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. 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. 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. 36. RESULTSMODALITY SURGERY SURG+POST GAMMA KNIEF VS OP RT RADIOSURGERY SURG+POSTO VS P RT RT ALONERESULTS Park et.al Grigsby et al Maschiro.et 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. 37. COMPLICATIONS OF RADIOTHERAPY ACUTE REACTIONS1. Fatigue2. Focal alopecia3. Otitis CHRONIC REACTIONS1. Hypopituitarism2. Damage to optic apparatus3. Secondary brain tumours4. Brain necrosis
  38. 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. 39. THANKYOU

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