Radioterapia degli adenomi ipofisari

Transcription

1 Radioterapia degli adenomi ipofisari G Minniti Radiation Oncology, Sant Andrea Hospital, University of Rome Sapienza, and IRCCS Neuromed, Pozzilli (IS) Roma 6-9 Novembre 14

2 ! Outline " Radiation techniques " FSRT and SRS results for pituitary adenomas " FSRT vs SRS (indications) " Nonfunctioning pituitary adenomas: early vs delayed treatment " Secreting adenomas

3 ! Stereotactic techniques " Radiosurgery (SRS) either Gamma Knife (GK), Cyberknife, or a l i n e a r a c c e l e r a t o r (LINAC), delivered as a single treatment; " Stereotactic fractionated radiotherapy (FSRT) delivered as a fractionated treatment.

4 " Target delineation AIRO; Genova,

5 " Treatment planning AIRO; Genova,

6 ! Treatment delivery

7 " Immobilization Technique Immobilization system Fractionation Accuracy Conventional RT mask conventional (25-30) 5-7 mm IMRT mask conventional (25-30) 3-5 mm Radiosurgery LINAC system stereotactic fixed frame single session < 1mm GammaKnife system stereotactic fixed frame single session < 1mm Proton RS stereotactic fixed frame single session < 1mm CyberKnife system stereotactic mask single session/ hypofractionation (3-5) < 1mm Proton therapy stereotactic relocatable conventional (25-30) 1-2 mm FSRT frame/mask stereotactic relocatable frame/mask conventional (25-30) 1-2 mm Minniti et al, Rad Oncol 2010

8 " Clinical results of RT for pituitary adenoma Efficacy Tumor control Endocrine control Toxicity

9 " FSRT for NF pituitary adenoma authors patients follow-up control rate late toxicity (%) median (months) % visual Hypopituitarism Coke * Mitsumori * at 3 years 0 20 Milker-Zabel * at 5 years 4 5 Paek at 5 years 3 6 Colin * at 5 years 2 29 at 5 years Minniti * at 5 years 1 22 Selch * Kong * at 4 years 0 11 *series include secreting pituitary adenomas Minniti et al, Neurosurgical reviews 2008

10 ! FSRT for secreting pituitary adenomas 5-year control 97% 50% at 5 years Minniti et al, Clin Endocrinol 2006

11 ! Radiosurgery for pituitary adenomas " NF adenomas " Secreting adenomas

12 ! Radiosurgery for NFAs Author Number follow-up tumor control patients (months) % Losa at 5 yrs Liscak at 5 yrs Pollock at 5 yrs Park at 5 yrs Starke at 5 yrs Losa at 10 yrs wilson at 5 yrs Sheehan at 5 yrs Lee at 5 yrs Total at 5 years

13 ! Radiosurgery for acromegaly Author Number follow-up normal GH patients (months) % Attanasio at 5 yrs Jezkova at 5 yrs Voges at yrs Total Pollock at at 5 yrs years Vik-mo at 10 yrs Losa at 10 yrs Ronchi at 10 yrs Iwai at 5 yrs Sheehan at 5 yrs Franzin at 5 yrs

14 ! Radiosurgery for Cushing Author Number follow-up normal patients months ACTH % Degerblad Sheehan Hoybye Kobayashi Devin Jane >18 63 Castinetti Jagannathan Pollock Sheehan Wilson Total

15 ! Radiosurgery for prolactinomas Author Number follow-up normal patients (months) PRL % Pan et al Lim et a Mokry et al Landolt et al Pan et al Choi et al Jane et al 19 >18 11 Pouratian et al Jezkova et al Sheehan et al Total

16 " Open issues! FSRT vs SRS

17 " Results of SRS/FSRT in pituitary tumors " NF adenomas 90-95% at 5 years / % at 5 years " GH-secreting adenomas 40-55% at 5 years / 30-55% at 5 years " ACTH-secreting adenomas 40-60% at 5 years / 70-80% at 5 years " PRL-secreting adenomas 30-50% at 5 years / 30-50% at 5 years Minniti et al, Rev Endocr Metab Disord. 2009

18 " Limitation of SRS Size of adenoma (more than cm) Proximity to the optic chiasm (< 2-3 mm)

19 ! Radiation tolerance to SRS " Radiation induced optic neuropathy (RON) dose to optic apparatus incidence of RON < 10 Gy 0-3% Gy 2-5% > 12 Gy >10%

20 NF pituitary adenoma A B C D E F G H

21 Surgery followed by SRS for an ACTH-secreting pituitary adenoma Pre-surgery Post-surgery

22 Hypofractionated SRT

23 " Median radiation doses to cavernous sinus, optic nerves and chiasm in patients treated with multi-fraction SRS (5 5 Gy) Minniti et al, Rad Oncol 2014

24 " Open issues! Which nonfunctioning adenomas need treatment?! Immediate versus delayed treatment

25 IMRS for residual pituitary adenoma

26 NF pituitary adenoma Pre-surgery Intraoperative MRI 2 years post-srt

27 " Open issues! Indications for secreting pituitary adenomas: hormone normalization

28 ! Hormone control in acromegaly after RT GH ng/ml IGF-I ng/ml years years Minniti et al, Clin Endocrinol 2005

29 ! SRS for acromegaly retrospective comparison SRS 25 Gy in one fraction 16 patients ( ) vs FSRT 40 Gy in 20 fractions 50 patients ( ) SRS FSRT mean time to normalization of GH & IGF-1 (years) pretreatment GH (miu/l) mean 18.0* 29.7 range Landolt et al 1998

30 ! GH after SRS " median decrease in GH and IGF-I after GK SRS Attanasio et al 2003

31 ! Results of SRS/FSRT for secreting pituitary tumors " GH-secreting adenomas 40-55% vs 30-55% at 5 years " ACTH-secreting adenomas 40-60% vs 70-80% at 5 years " PRL-secreting adenomas 30-50% vs 30-50% at 5 years Minniti et al, Rev Endocr Metab Disord. 2009

32 ! Conclusions " Stereotactic radiation techniques are effective and may reduce the potential long-term toxicity of radiation; " Both FSRT and SRS are feasible options for patients with otherwise uncontrolled pituitary adenomas; " SRS should be employed for small- to moderatesized (< cm) adenomas 3-5 mm away from the optic chiasm.

33 .Grazie per l attenzione...