Elsevier

Surgical Neurology

Volume 72, Issue 3, September 2009, Pages 248-255
Surgical Neurology

Pituitary
Stereotactic radiosurgery for pituitary metastases

https://doi.org/10.1016/j.surneu.2008.06.003Get rights and content

Abstract

Background

We evaluated the role of Gamma Knife SRS in the multidisciplinary management of metastatic cancer to the pituitary gland.

Methods

We retrospectively reviewed records of 18 consecutive pituitary metastasis patients who underwent Gamma Knife SRS during a 21-year experience. The median patient age was 57.6 years (range, 27.0-81.1 years). There were 5 patients who had initial surgical resection of their pituitary metastasis, 5 who had fractionated radiation, and 7 who had CT before SRS. The median radiosurgery target volume was 3.5 mL (range, 0.2-18.0 mL), and the median marginal dose was 13.0 Gy (range, 9-18 Gy).

Results

The overall survival after SRS at 3, 6, and 12 months, respectively, was 66%, 36%, and 18%. The median survival after SRS was 5.2 months. The progression-free survival after SRS was 100% and 66.7% at 6 and 12 months, respectively. The only factor associated with an improved overall survival was younger age at presentation. Diabetes insipidus improved in 3 (42.9%) of 7 patients. Neurological symptoms or signs improved in 4 (50.0%) of 8 patients. Three (16.7%) patients developed new neurological deficits due to tumor progression despite SRS.

Conclusion

Development of a pituitary metastasis is an ominous finding in the context of systemic cancer. Stereotactic radiosurgery is an effective palliative approach for most patients with pituitary metastasis.

Introduction

The development of a pituitary metastasis is rare within the context of cancer. The frequency of metastases confirmed at autopsy is higher, representing up to 28% of all brain metastases) [15], [11], [21]. Most patients who develop such tumors remain clinically asymptomatic [1], [14]. Although virtually all malignancies can metastasize to the pituitary gland, the most frequent is breast, followed by lung, gastrointestinal tract, and prostate [15], [17], [22]. Diabetes insipidus, with or without other signs of hypopituitarism, is the most frequent presenting symptom [6], [7], [10].

Surgical resection preceding fractionated RT is recommended if no known diagnosis of systemic cancer is present [16]. Most such patients experience the development of permanent DI and Panhypo. Whole-brain RT is typically recommended for patients with known systemic cancer [15].

Stereotactic radiosurgery facilitates submillimeter accurate delivery of radiation in a single outpatient procedure. However, the role of SRS in the treatment of pituitary metastases is not well documented because there are only few published outcome studies [[8], [19]]. This report reviews our 20-year experience with SRS for pituitary metastases. We evaluated tumor control, patient survival, pituitary function, AREs, and other variables that might affect treatment outcomes.

Section snippets

Patient population

Between 1988 and 2007, 2522 patients with brain metastases underwent SRS at the University of Pittsburgh. Eighteen (0.7%) patients had a pituitary metastasis. The series includes 11 men and 7 women with a median age of 57.6 years (range, 27.0-81.1 years). A total of 13 patients had only a pituitary metastasis, and 5 had these tumors in the context of multiple brain metastases (range, 2-7). Three patients were diagnosed at the time of a transsphenoidal surgical resection for their pituitary

Results

At last follow-up, 2 (11.1%) patients were alive and 16 patients (88.9%) had died an average of 6.0 months after radiosurgery (range, 0.5-19.4 months) and an average of 33 months after initial diagnosis of their primary site (range, 2.8-100 months). The overall survival after SRS was 65.8%, 35.9%, and 17.9% at 3, 6, and 12 months, respectively (Fig. 1). The median survival after SRS was 5.2 months. The overall survival after the initial primary diagnosis was 66.7%, 33.3%, and 13.3% at 1, 3, and

Discussion

In the face of active systemic cancer, skull-base metastases develop in approximately 4% of patients In contrast pituitary gland metastases are even rarer tumors. Many pituitary metastases remain asymptomatic and are found at incidentally autopsy. Less than 10% of pituitary metastases are symptomatic [22]. Most (≥66%) of all pituitary metastases originate from breast and lung cancer [11]. Renal cancer pituitary metastases represent as few as 2.5% of all pituitary metastases. Other primary

Acknowledgments

The work described in this report was funded by a grant (to H.K.) from the Osaka Medical Research Foundation for Incurable Diseases.

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    Conflict of interest notification: Dr Lunsford, Dr Kondziolka, and Dr Niranjan are consultants with AB Elekta. Doctor Lunsford is a stockholder in AB Elekta.

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