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Cote DJ, Iuliano SL, Catalino MP, Laws ER. Optimizing pre-, intra-, and postoperative management of patients with sellar pathology undergoing transsphenoidal surgery. Neurosurg Focus 2021; 48:E2. [PMID: 32480374 DOI: 10.3171/2020.3.focus2043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 03/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Perioperative management of patients with sellar lesions is complex, requiring input from a multidisciplinary team of specialists for ongoing management of both endocrinological and neurosurgical issues. Here, the authors reviewed the experience of a single multidisciplinary center over 10 years to identify key postoperative practices that ensure positive outcomes for patients with sellar lesions who undergo transsphenoidal surgery. METHODS The authors performed a retrospective review of all transsphenoidal operations carried out by the senior author at a single center from April 2008 through November 2018. They included only adult patients and recorded perioperative management. They also reviewed the evolution of clinical practices for perioperative care at their institution to identify strategies for ensuring positive patient outcomes, and they reviewed the literature on select related topics. RESULTS In total, 1023 operations in 928 patients were reviewed. Of these, 712 operations were for pituitary adenomas (69.6%), and 122 were for Rathke cleft cysts (11.9%). The remainder included operations for craniopharyngiomas (3.6%), arachnoid cysts (1.7%), pituitary tumor apoplexy (1.0%), and other sellar pathologies (12.2%). Among the reviewed operations, the median hospital stay was 3 days (IQR 2-3). Patient management details during the pre-, intra-, and postoperative periods were identified, including both shared characteristics of all patients undergoing transsphenoidal surgery and unique characteristics that are specific to certain lesion types or patient populations. CONCLUSIONS Patients with sellar lesions who undergo transsphenoidal surgery require complex, multidisciplinary perioperative care to monitor for common adverse events and to improve outcomes, but there is a dearth of high-quality evidence guiding most perioperative practices. Here, the authors reviewed practices at their institution across more than 1000 transsphenoidal operations that may help ensure successful patient outcomes.
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Affiliation(s)
- David J Cote
- 1Pituitary/Neuroendocrine Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Sherry L Iuliano
- 1Pituitary/Neuroendocrine Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Michael P Catalino
- 1Pituitary/Neuroendocrine Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and.,2Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina
| | - Edward R Laws
- 1Pituitary/Neuroendocrine Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and
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2
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Ramos-Prudencio R, Pérez-Álvarez SI, Flores-Balcazar CH, de León-Alfaro MA, Herrera-González JA, Elizalde-Cabrera J, Rubalcava-Ortega J, Espinoza-Alvarado L, Balderrama-Ibarra RI. Radiotherapy for the treatment of pituitary adenomas: A dosimetric comparison of three planning techniques. Rep Pract Oncol Radiother 2020; 25:586-593. [PMID: 32508534 PMCID: PMC7264003 DOI: 10.1016/j.rpor.2020.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022] Open
Abstract
AIM Our goal was to compare conformal 3D (C3D) radiotherapy (RT), modulated intensity RT (IMRT), and volumetric modulated arc therapy (VMAT) planning techniques in treating pituitary adenomas. BACKGROUND RT is important for managing pituitary adenomas. Treatment planning advances allow for higher radiation dosing with less risk of affecting organs at risk (OAR). MATERIALS AND METHODS We conducted a 5-year retrospective review of patients with pituitary adenoma treated with external beam radiation therapy (C3D with flattening filter, flattening filter-free [FFF], IMRT, and VMAT). We compared dose-volume histogram data. For OARs, we recorded D2%, maximum, and mean doses. For planning target volume (PTV), we registered V95%, V107%, D95%, D98%, D50%, D2%, minimum dose, conformity index (CI), and homogeneity index (HI). RESULTS Fifty-eight patients with pituitary adenoma were included. Target-volume coverage was acceptable for all techniques. The HI values were 0.06, IMRT; 0.07, VMAT; 0.08, C3D; and 0.09, C3D FFF (p < 0.0001). VMAT and IMRT provided the best target volume conformity (CI, 0.64 and 0.74, respectively; p < 0.0001). VMAT yielded the lowest doses to the optic pathway, lens, and cochlea. The position of the neck in extreme flexion showed that it helps in planning mainly with VMAT by allowing only one arc to be used and achieving the desired conformity, decreasing the treatment time, while allowing greater protection to the organs of risk using C3D, C3DFFF. CONCLUSIONS Our results confirmed that EBRT in pituitary adenomas using IMRT, VMAT, C3D, C3FFF provide adequate coverage to the target. VMAT with a single arc or incomplete arc had a better compliance with desired dosimetric goals, such as target coverage and normal structures dose constraints, as well as shorter treatment time. Neck extreme flexion may have benefits in treatment planning for better preservation of organs at risk. C3D with extreme neck flexion is an appropriate treatment option when other treatment techniques are not available.
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Key Words
- C3D, conformal three-dimensional radiotherapy
- CFRT, conventional fractionated radiotherapy
- CI, conformity index
- CT, computed tomography
- CTV, clinical target volume
- Conformal radiotherapy
- DVH, dose-volume histogram
- EBRT, external beam radiation therapy
- ESAPI, Eclipse Scripting Application Programming Interface
- FF, flattening filter
- FFF, flattening filter free
- GTV, gross tumor volume
- HI, homogeneity index
- IMRT
- IMRT, modulated intensity radiotherapy
- MRI, magnetic resonance imaging
- OAR, organs at risk
- PTV, planning target volume
- Pituitary adenomas
- RION, radiation-induced neuropathy
- RT, radiotherapy
- SRS, stereotactic radiosurgery
- VMAT
- VMAT, volumetric modulated arc therapy
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Affiliation(s)
- Rubi Ramos-Prudencio
- Department of Radiotherapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Sandra Ileana Pérez-Álvarez
- Department of Radiotherapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Christian Haydée Flores-Balcazar
- Department of Radiotherapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Mayra Angélica de León-Alfaro
- Department of Radiotherapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - José Alfredo Herrera-González
- Division of Radiotherapy, Instituto Nacional de Cancerología, 22 San Fernando Ave, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Jonathan Elizalde-Cabrera
- Division of Radiotherapy, Instituto Nacional de Cancerología, 22 San Fernando Ave, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Johnatan Rubalcava-Ortega
- Department of Neuroimaging, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Lissett Espinoza-Alvarado
- Department of Neuroimaging, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez, Sección XVI, Tlalpan, México City 14080, Mexico
| | - Ricardo Iván Balderrama-Ibarra
- Department of Radiotherapy, Instituto Mexicano Del Seguro Social (IMSS), Centro Médico Nacional de Occidente, Universidad de Guadalajara, Independencia Oriente, Guadalajara 44340, Mexico
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Abstract
Cushing's disease (CD) is caused by a pituitary tumour that secretes adrenocorticotropin (ACTH) autonomously, leading to excess cortisol secretion from the adrenal glands. The condition is associated with increased morbidity and mortality that can be mitigated by treatments that result in sustained endocrine remission. Transsphenoidal pituitary surgery (TSS) remains the mainstay of treatment for CD but requires considerable neurosurgical expertise and experience in order to optimize patient outcomes. Up to 90% of patients with microadenomas (tumour below 1 cm in largest diameter) and 65% of patients with macroadenomas (tumour at or above 1 cm in greatest diameter) achieve endocrine remission after TSS by an experienced surgeon. Patients who are not in remission postoperatively or those who relapse may benefit from undergoing a second pituitary operation. Alternatively, radiation therapy to the sella with interim medical therapy, or bilateral adrenalectomy, can be effective as definitive treatments of CD. Medical therapy is currently adjunctive in most patients with CD and is generally prescribed to patients who are about to receive radiation therapy and will be awaiting its salutary effects to occur. Available treatment options include steroidogenesis inhibitors, centrally acting agents and glucocorticoid receptor antagonists. Several novel agents are in clinical trials and may eventually constitute additional treatment options for this serious condition.
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Affiliation(s)
- N A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - B M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Vilar L, Albuquerque JL, Lyra R, Trovão Diniz E, Rangel Filho F, Gadelha P, Thé AC, Ibiapina GR, Gomes BS, Santos V, Melo da Fonseca M, Frasão Viana K, Lopes IG, Araújo D, Naves L. The Role of Isotretinoin Therapy for Cushing's Disease: Results of a Prospective Study. Int J Endocrinol 2016; 2016:8173182. [PMID: 27034666 PMCID: PMC4789464 DOI: 10.1155/2016/8173182] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Accepted: 01/20/2016] [Indexed: 11/18/2022] Open
Abstract
Objective. This prospective open trial aimed to evaluate the efficacy and safety of isotretinoin (13-cis-retinoic acid) in patients with Cushing's disease (CD). Methods. Sixteen patients with CD and persistent or recurrent hypercortisolism after transsphenoidal surgery were given isotretinoin orally for 6-12 months. The drug was started on 20 mg daily and the dosage was increased up to 80 mg daily if needed and tolerated. Clinical, biochemical, and hormonal parameters were evaluated at baseline and monthly for 6-12 months. Results. Of the 16 subjects, 4% (25%) persisted with normal urinary free cortisol (UFC) levels at the end of the study. UFC reductions of up to 52.1% were found in the rest. Only patients with UFC levels below 2.5-fold of the upper limit of normal achieved sustained UFC normalization. Improvements of clinical and biochemical parameters were also noted mostly in responsive patients. Typical isotretinoin side-effects were experienced by 7 patients (43.7%), though they were mild and mostly transient. We also observed that the combination of isotretinoin with cabergoline, in relatively low doses, may occasionally be more effective than either drug alone. Conclusions. Isotretinoin may be an effective and safe therapy for some CD patients, particularly those with mild hypercortisolism.
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Affiliation(s)
- Lucio Vilar
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - José Luciano Albuquerque
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Ruy Lyra
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Erik Trovão Diniz
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Frederico Rangel Filho
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Patrícia Gadelha
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Ana Carolina Thé
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - George Robson Ibiapina
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Barbara Sales Gomes
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Vera Santos
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Maíra Melo da Fonseca
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Karoline Frasão Viana
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Isis Gabriella Lopes
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Douglas Araújo
- Division of Endocrinology, Hospital das Clínicas, Pernambuco Federal University, Avenida Professor Moraes Rego, 1235, Cidade Universitária, 50670-901 Recife, PE, Brazil
| | - Luciana Naves
- Division of Endocrinology, Brasilia University Hospital, Brasilia, DF, Brazil
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Abstract
INTRODUCTION There has been growing interest on medical therapy for the management of Cushing's disease (CD), particularly in cases of persistent or recurrent hypercortisolism. Ketoconazole, an inhibitor of adrenal steroidogenesis, is the most widely used drug, whereas cabergoline and pasireotide are the most promising centrally acting agents. The main purpose of this review article is to highlight the options of medical treatment for CD, with a special emphasis on combination therapies, a topic that has only been addressed by a limited number of studies. CONCLUSIONS According to the results of these studies, combination therapies involving medications with additive or synergistic effects on ACTH and cortisol secretion seem quite attractive as they yield higher probability of longterm control of the hypercortisolism at lower doses, a lower incidence of side-effects, and possibly a lower rate of treatment escapes. Currently, ketoconazole, cabergoline, and pasireotide are the best drugs to be prescribed in combination.
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Affiliation(s)
- Lucio Vilar
- Division of Endocrinology, Hospital das Clínicas, Federal University of Pernambuco, Rua Clovis Silveira Barros, 84/1202, Boa Vista, Recife, CEP 50.050-270, Brazil,
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