Search

ObjectiveRecurrent or residual adenomas are frequently treated with Gamma Knife radiosurgery (GKRS). The most common complication after GKRS for pituitary adenomas is hypopituitarism. In the current study, the authors detail the timing and types of hypopituitarism in a multicenter, international cohort of pituitary adenoma patients treated with GKRS.MethodsSeventeen institutions pooled clinical data obtained from pituitary adenoma patients who were treated with GKRS from 1988 to 2016. Patients who had undergone prior radiotherapy were excluded. A total of 1023 patients met the study inclusion criteria. The treated lesions included 410 nonfunctioning pituitary adenomas (NFPAs), 262 cases of Cushing’s disease (CD), and 251 cases of acromegaly. The median follow-up was 51 months (range 6–246 months). Statistical analysis was performed using a Cox proportional hazards model to evaluate factors associated with the development of new-onset hypopituitarism.ResultsAt last follow-up, 248 patients had developed new pituitary hormone deficiency (86 with NFPA, 66 with CD, and 96 with acromegaly). Among these patients, 150 (60.5%) had single and 98 (39.5%) had multiple hormone deficiencies. New hormonal changes included 82 cortisol (21.6%), 135 thyrotropin (35.6%), 92 gonadotropin (24.3%), 59 growth hormone (15.6%), and 11 vasopressin (2.9%) deficiencies. The actuarial 1-year, 3-year, 5-year, 7-year, and 10-year rates of hypopituitarism were 7.8%, 16.2%, 22.4%, 27.5%, and 31.3%, respectively. The median time to hypopituitarism onset was 39 months.In univariate analyses, an increased rate of new-onset hypopituitarism was significantly associated with a lower isodose line (p = 0.006, HR = 8.695), whole sellar targeting (p = 0.033, HR = 1.452), and treatment of a functional pituitary adenoma as compared with an NFPA (p = 0.008, HR = 1.510). In multivariate analyses, only a lower isodose line was found to be an independent predictor of new-onset hypopituitarism (p = 0.001, HR = 1.38).ConclusionsHypopituitarism remains the most common unintended effect of GKRS for a pituitary adenoma. Treating the target volume at an isodose line of 50% or greater and avoiding whole-sellar radiosurgery, unless necessary, will likely mitigate the risk of post-GKRS hypopituitarism. Follow-up of these patients is required to detect and treat latent endocrinopathies.

Background Stereotactic radiosurgery (SRS) and resection are treatment options for patients with facial nerve schwannomas without mass effect. Objective This article evaluates outcomes of patients treated with SRS versus resection + SRS. Method We retrospectively compared 43 patients treated with SRS to 12 patients treated with resection + SRS. The primary study outcome was unfavorable combined endpoint, defined as worsening or new clinical symptoms, and/or tumor radiological progression. SRS (38.81 ± 5.3) and resection + SRS (67.14 ± 11.8) groups had similar clinical follow-ups. Results At the time of SRS, the tumor volumes of SRS (mean ± standard error; 1.83 ± 0.35 mL) and resection + SRS (2.51 ± 0.75 mL) groups were similar. SRS (12.15 ± 0.08 Gy) and resection + SRS (12.16 ± 0.14 Gy) groups received similar radiation doses. SRS group (42/43, 98%) had better local tumor control than the resection + SRS group (10/12, 83%, p = 0.04). Most of SRS (32/43, 74%) and resection + SRS (10/12, 83%) group patients reached a favorable combined endpoint following SRS (p = 0.52). Considering surgical associated side effects, only 2/10 patients of the resection + SRS group reached a favorable endpoint (p < 0.001). Patients of SRS group, who are > 34 years old (p = 0.02), have larger tumors (> 4 mL, 0.04), internal auditory canal (IAC) segment tumor involvement (p = 0.01) were more likely to reach an unfavorable endpoint. Resection + SRS group patients did not show such a difference. Conclusion While resection is still needed for larger tumors, SRS offers better clinical and radiological outcomes compared to resection followed by SRS for facial schwannomas. Younger age, smaller tumors, and non-IAC situated tumors are factors that portend a favorable outcome. [ABSTRACT FROM AUTHOR]

Objective  Meningiomas are the second most common tumors in neurofibromatosis type 2 (NF-2). Microsurgery is challenging in NF-2 patients presenting with skull base meningiomas due to the intrinsic risks and need for multiple interventions over time. We analyzed treatment outcomes and complications after primary Gamma Knife radiosurgery (GKRS) to delineate its role in the management of these tumors. Methods  An international multicenter retrospective study approved by the International Radiosurgery Research Foundation was performed. NF-2 patients with at least one growing and/or symptomatic skull base meningioma and 6-month follow-up after primary GKRS were included. Clinical and radiosurgical parameters were recorded for analysis. Results  In total, 22 NF-2 patients with 54 skull base meningiomas receiving GKRS as primary treatment met inclusion criteria. Median age at GKRS was 38 years (10–79 years). Most lesions were located in the posterior fossa (55.6%). Actuarial progression free survival (PFS) rates were 98.1% at 2 years and 90.0% at 5 and 10 years. The median follow-up time after initial GKRS was 5.0 years (0.6–25.5 years). Tumor volume at GKRS was a predictor of tumor control. Lesions >5.5 cc presented higher chances to progress after radiosurgery (p  = 0.043). Three patients (13.64%) developed adverse radiation effects. No malignant transformation or death due to meningioma or radiosurgery was reported. Conclusions  GKRS is effective and safe in the management of skull base meningiomas in NF-2 patients. Tumor volume deserve greater relevance during clinical decision-making regarding the most appropriate time to treat. GKRS offers a minimally invasive approach of particular interest in this specific group of patients. [ABSTRACT FROM AUTHOR]

Objective: Ablative procedures in the treatment of intractable pain are experiencing a renaissance despite the frequent overuse of neuromodulation techniques. Here we present the results of centro-lateral thalamotomy (CLT) in the facial and thalamic pain. Methods and patients: Between 2018 and 2021, we performed unilateral CLT in 16 patients but for the short follow-up we present here 9 of them (F:M=7:2; median age 65 years [range 49–79]) suffering from various severe pain syndromes (4 trigeminal deafferenation pain, 2 trigeminal neuropathic pain, 2 postherpetic trigeminal neuralgia, 1thalamic pain), in whom previous treatment had failed. The median follow up period was 24 months (range 6–28 months). The Leksell Stereotactic Frame, GammaPlan Software (Elekta) and T1- and T2-weighted sequences of magnetic resonance imaging acquired at 1.5 T were used for localization of the targeted central lateral posterior thalamus (CLp). The CLp was localized 6–8 mm lateral to the wall of the 3rd ventricle, 1 mm anterior to the posterior commissure and 5-6 mm superior to the intercommissural line. The CLT was performed by Leksell Gamma Knife with an applied dose ranging from 138 to 145 Gy; single shot, 4 mm collimator. In 7 patients, radiofrequency thermolesion (80°C/60s) at the same target was performed before or after gamma knife CLT to improve the pain relief. Decreased pain intensity to less than 50 - 60% of the previous level was considered as the successful treatment. Results: Initial successful results were achieved in 5 (55.5 %) of the patients. The relief has been achieved after a median latency of 4 - 6 months (range 2–12 months). No neurological deficits were observed. Conclusions: Our results suggest that centro-lateral thalamotomy in patients suffering from severe pain syndromes is a relatively successful and safe method that can be used even in severely affected patients. [ABSTRACT FROM AUTHOR]

Introduction: Hypophysectomy is a method used in analgesia in patients with painfull bone metastases. The pain relief after this procedure is not pathophysiologically fully understood but the stimulation of hypothalamic non-opioid pain suppression system is prefered theory nowadays. Firstly this procedure was performed by classical transsphenoidal surgical approach or stereotactic thermocoagulation. In only a few studies Leksell gamma knife (LGK) was used for radiosurgical hypophysectomy. This single-centre study aimed to evaluate the effect and safety of the LGK hypophysectomy in a patient with malignant disease suffering from intractable cancer-related pain. Methods: From 1996 to 2019 we enrolled 19 patients (11F), mean age 59,4 years with the diagnosis of disseminated carcinoma included breast cancer (41%), prostate cancer (23%), lung cancer(18%), kidney cancer (6%), laryngeal cancer (6%) and rectal cancer (6%). All patients underwent radiosurgical hypophysectomy on LGK (model C and Perfexion). The prescription dose was 75-100Gy on 50% isodose line, the maximal dose on the optic pathways was 8-12Gy. Results: The effect of radiosurgical hypophysectomy on pain relief was evaluated in nine patients. In the rest 10 patients, the evaluation was not possible due to bad clinical status (Karnofsky < 60%), they did not come for a visit or they died in consequence of the malignant disease before the effect onset which was from 2 to 4 weeks. In all evaluated patients pain relief was achieved (0-60% of pre-procedural pain). The effect of the hypophysectomy was lasting for the rest of their lives (the mean follow-up period was 14 months). In two patients we observed a side effect - hypocortisolism and diabetes insipidus with good response on substitutional therapy. No other adverse events were observed. Conclusion: Our results suggest that the LGK hypophysectomy is permanently effective and safe procedure to reduce a cancer-related intractable pain especially in bone metastases of hormonally active tumours. [ABSTRACT FROM AUTHOR]

Objective: Rathke’s cleft cysts (RCC) are sellar collections from an incompletely regressed Rathke’s pouch. Common symptoms can include headaches, visual loss, and endocrinopathy. In some cases of symptomatic or growing RCC, surgery is required. Recurrence after surgery is common (10-40%). Stereotactic radiosurgery (SRS) has been used in an attempt to control growth and symptoms, but outcomes are not well known. We sought to study the outcomes of Rathke’s cleft cysts following Gamma Knife radiosurgery for both salvage and initial treatment. Methods: We reviewed the outcomes of 25 Rathke’s cleft cyst patients that had stereotactic radiosurgery between 2001 and 2020. Four patients received upfront SRS, and 21 were treated with salvage SRS. Diagnosis was based on imaging or histopathology. Cyst control was defined as stability or regression of the cyst. Kaplan-Meier analysis was used to determine time-to-recurrence and determine potential factors for recurrence. Results: The respective median clinical follow-up and margin dose were 6.5 years and 12 Gy. Overall control was achieved in 19/25 (76%) patients, and four recurrences required further intervention. For those that recurred, the average time to recurrence was 35.6 months. Visual recovery occurred in 14/15 (93.3%) patients, and no new post-radiosurgery visual deficits occurred. The presence of pre-treatment visual deficit was often an indicator of regrowth. 3 of 3 patients with hyperprolactinemia resolved after SRS. New endocrinopathy related to radiosurgery was noted in 5/25 (20%) patients, all of which were thyroid and/ or cortisol axis related. Upfront SRS was used in four patients. No new endocrinopathies or visual deficits developed after upfront SRS, and the single patient with a pretreatment visual deficit recovered. One of the four upfront SRS patients recurred, after 7.5 years. Conclusion: Stereotactic radiosurgery produced effective recovery of visual deficits, and carries a low risk for new visual deficits. Cyst control was achieved in about three quarters of the patients. Following radiosurgery, patients without pre-treatment visual deficits are less likely to regrow. Endocrinopathy can occur after radiosurgery, similar to other sellar mass lesions. Initial radiosurgery shows the potential for long-term cyst control, with improvement of symptoms and low risk for complications. [ABSTRACT FROM AUTHOR]

Background: Higher risk of secondary brain tumor, carotid stenosis and stroke has been reported after conventional sella irradiation for pituitary neuroendocrine tumors (PitNET). Stereotactic radiosurgery (SRS), which is a more focused approach, is now increasingly used instead. The aim was to assess the risk of secondary brain tumor, carotid stenosis/occlusion and stroke after SRS., Methods: In this multicentric retrospective study, 2,254 patients with PitNET were studied, 1,377 in the exposed group and 877 in the control group., Results: There were 9,840.1 patient-years at risk for the SRS and 5,266.5 for the control group. The 15-year cumulative probability of secondary intracranial tumor was 2.3% (95%CI:0.5%, 4.1%) for SRS and 3.7% (95%CI:0%, 8.7%) for the control group (p=0.6), with an incidence rate of 1.32 per 1,000 and 0.95 per 1,000, respectively. SRS was not associated with increased risk of tumorigenesis when stratified by age (HR: 1.59 [95%CI: 0.57, 4.47], p=0.38). The 15-year probability of new carotid stenosis/occlusion was 0.9% (95%CI: 0.2, 1.6) in the SRS and 2% (95%CI: 0, 4.4) in the control group (p=0.8). The 15-year probability of stroke was 2.6% (95%CI: 0.6%, 4.6%) in the SRS and 11.1% (95%CI: 6%, 15.9%) in the control group (p<0.001). In cox multivariate analysis stratified by age, SRS (HR 1.85[95%CI:0.64, 5.35], p=0.26) was not associated with risk of new stroke., Conclusion: No increased risk of long-term secondary brain tumor, new stenosis or occlusion and stroke was demonstrated in SRS group compared to control in this study with imaging surveillance., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Cerebral cavernous malformations (CCMs) frequently manifest with haemorrhages. Stereotactic radiosurgery (SRS) has been employed for CCM not suitable for resection. Its effect on reducing haemorrhage risk is still controversial. The aim of this study was to expand on the safety and efficacy of SRS for haemorrhagic CCM., Methods: This retrospective multicentric study included CCM with at least one haemorrhage treated with single-session SRS. The annual haemorrhagic rate (AHR) was calculated before and after SRS. Recurrent event analysis and Cox regression were used to evaluate factors associated with haemorrhage. Adverse radiation effects (AREs) and occurrence of new neurological deficits were recorded., Results: The study included 381 patients (median age: 37.5 years (Q1-Q3: 25.8-51.9) with 414 CCMs. The AHR from diagnosis to SRS excluding the first haemorrhage was 11.08 per 100 CCM-years and was reduced to 2.7 per 100 CCM-years after treatment. In recurrent event analysis, SRS, HR 0.27 (95% CI 0.17 to 0.44), p<0.0001 was associated with a decreased risk of haemorrhage, and the presence of developmental venous anomaly (DVA) with an increased risk, HR 1.60 (95% CI 1.07 to 2.40), p=0.022. The cumulative risk of first haemorrhage after SRS was 9.4% (95% CI 6% to 12.6%) at 5 years and 15.6% (95% CI% 9 to 21.8%) at 10 years. Margin doses> 13 Gy, HR 2.27 (95% CI 1.20 to 4.32), p=0.012 and the presence of DVA, HR 2.08 (95% CI 1.00 to 4.31), p=0.049 were factors associated with higher probability of post-SRS haemorrhage. Post-SRS haemorrhage was symptomatic in 22 out of 381 (5.8%) patients, presenting with transient (15/381) or permanent (7/381) neurological deficit. ARE occurred in 11.1% (46/414) CCM and was responsible for transient neurological deficit in 3.9% (15/381) of the patients and permanent deficit in 1.1% (4/381) of the patients. Margin doses >13 Gy and CCM volume >0.7 cc were associated with increased risk of ARE., Conclusion: Single-session SRS for haemorrhagic CCM is associated with a decrease in haemorrhage rate. Margin doses ≤13 Gy seem advisable., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The optimal management of patients with incidental meningiomas remains unclear. The aim of this study was to characterize the radiologic and neurological outcomes of expectant and stereotactic radiosurgery (SRS) management of asymptomatic meningioma patients., Methods: Using data from 14 centers across 10 countries, the study compares SRS outcomes to active surveillance of asymptomatic meningiomas. Local tumor control of asymptomatic meningiomas and development of new neurological deficits attributable to the tumor were evaluated in the SRS and conservatively managed groups., Results: In the unmatched cohorts, 727 meningioma patients underwent SRS and were followed for a mean of 57.2 months. In the conservatively managed cohort, 388 patients were followed for a mean of 43.5 months. Tumor control was 99.0% of SRS and 64.2% of conservatively managed patients (P < .001; OR 56.860 [95% CI 26.253-123.150]). New neurological deficits were 2.5% in the SRS and 2.8% of conservatively managed patients (P = .764; OR 0.890 [95% CI 0.416-1.904]). After 1:1 propensity matching for patient age, tumor volume, location, and imaging follow-up, tumor control in the SRS and conservatively managed cohorts was 99.4% and 62.1%, respectively (P < .001; OR 94.461 [95% CI 23.082-386.568]). In matched cohorts, new neurological deficits were noted in 2.3% of SRS-treated and 3.2% of conservatively managed patients (P = .475; OR 0.700 [95% CI 0.263-1.863])., Conclusions: SRS affords superior radiologic tumor control compared to active surveillance without increasing the risk of neurological deficits in asymptomatic meningioma patients. While SRS and active surveillance are reasonable options, SRS appears to alter the natural history of asymptomatic meningiomas including tumor progression in the majority of patients treated., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)