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PRESENTED BY :Dr SANDIP KUMAR BARIK
              DEPT OF RADIOTHERAPY

MODERATOR: Dr RAJENDRA KUMAR
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
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
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 content



Modified from Lechan RM. Neuroendocrinology of Pituitary Hormone Regulation. Endocrinology and Metabolism Clinics 16:475-501, 1987
 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
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
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)
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
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
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
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
 INCREASED ACTH
 Causes cushing syndrome
 Central obesity
 Plethoric moon facies
 Purple striae,increased bruisability
 Glucose intolerence
 Acne,hirsuitism
 Proximal muscle weakness
 Hypertension
 Amennorhoea,infertility
FEATURES OF SELLAR MASS LESION
 PITUITARY
 Hypopituitarism


 OPTIC CHIASMA
 Bitemporal Hemianopia
 Superior temporal defect


 CAVERNOUS SINUS
 Ophthalmoplegia
 Ptosis
 Diplopia


 OTHERS
 Head ache
 Hydrocephalus
 Dementia
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
 STAGING WORKUP: Chest x ray
                       USG Whole abdomen

 General condition:
       Complete blood count
       Kidney function tests
       liver function test
       Urine analysis
 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
CLASSIFICATION OF PITUITARY TUMOURS
 ANATOMICAL SIZE
 Microadenoma(<10 mm)
 Macroadenoma(>10 mm)
 PHYSIOLOGICAL
 Ant pituitary

1.   Prolactin
2.   Growth hormone
3.   Adrenocorticotrophic hormone
4.   Leutinizing hormone
5.   Follicle stimulating hormone
6.   Thyroid stimulating hormone

 Post pituitary

1.   Oxytocin
2.   Vasopressin
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
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
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
MANAGEMENT
 Observation


 Surgery


 Radiotherapy
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
< 10 mm                                      > 10 mm


                                                       Evaluate for:
           Evaluate for                    •        Hormonal Hypersecretion
            Hormonal                        •       Hormonal Hyposecretion
          Hypersecretion
                                                •    Visual Changes/defects



                           Hormonal or Visual
Normal                       Abnormalities                    No Abnormalities



Observe                                                         Observe
                              Treatment
SURGERY
INDICATIONS
 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
 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
   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
COMPLICATIONS OF SURGERY
 CSF rhinorrhoea


 Meningitis


 Haemorrhage


 Stroke


 Damage to pituitary


 Visual loss
RADIOTHERAPY
 INDICATIONS


1.   Hypersecretion and mass effect due to large tumours

2.   Incomplete resection of tumour

3.   Progressive disease after surgery

4.   Recurrent tumours
RADIOTHERAPY
 TECHNIQUES


   Conventional External Beam Radiotherapy
   Manual planning
   2D Planning
   3D CRT


   Fractionated Stereotactic Radiation Therapy

   Gammaknief Radiosurgery
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
 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
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
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
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/#
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)
RESULTS
MODALITY     SURGERY           SURG+POST            GAMMA KNIEF
                VS             OP RT                RADIOSURGERY
             SURG+POSTO           VS
             P RT
                               RT ALONE
RESULTS      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
COMPLICATIONS OF RADIOTHERAPY
 ACUTE REACTIONS
1.   Fatigue
2.   Focal alopecia
3.   Otitis

    CHRONIC REACTIONS
1.   Hypopituitarism

2.   Damage to optic apparatus

3.   Secondary brain tumours

4.   Brain necrosis
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
THANKYOU

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Pituitary tumours

  • 1. PRESENTED BY :Dr SANDIP KUMAR BARIK DEPT OF RADIOTHERAPY MODERATOR: Dr RAJENDRA KUMAR
  • 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 content Modified 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 pituitary 1. Prolactin 2. Growth hormone 3. Adrenocorticotrophic hormone 4. Leutinizing hormone 5. Follicle stimulating hormone 6. Thyroid stimulating hormone  Post pituitary 1. Oxytocin 2. 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
  • 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 Visual Normal Abnormalities No Abnormalities Observe Observe Treatment
  • 24. SURGERY INDICATIONS  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  INDICATIONS 1. Hypersecretion and mass effect due to large tumours 2. Incomplete resection of tumour 3. Progressive disease after surgery 4. 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.
  • 37. RESULTS MODALITY SURGERY SURG+POST GAMMA KNIEF VS OP RT RADIOSURGERY SURG+POSTO VS P RT RT ALONE RESULTS 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
  • 38. COMPLICATIONS OF RADIOTHERAPY  ACUTE REACTIONS 1. Fatigue 2. Focal alopecia 3. Otitis  CHRONIC REACTIONS 1. Hypopituitarism 2. Damage to optic apparatus 3. Secondary brain tumours 4. Brain necrosis
  • 39. 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