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Ahmad M. Badran

Andrew S. Davidson

13 April 2017

TREAT NOW, OR LATER…

Residual Non-Functioning Pituitary Adenoma

• 37 yr old man presented with:

Headache (2/52)

Poor libido, reduced body hair, & infertility (12/12)

• Visual exam: Normal.

• Pituitary function test:

Testosterone 4.0

Otherwise NL

Case Presentation

Macquarie Neurosurgery 2

Macquarie Neurosurgery 3

Macquarie Neurosurgery 4

Residual pituitary

adenoma within the

Rt. cavernous sinus.

Stable over 18/12.

P – Patient with residual non-functioning pituitary adenoma post surgical debulking.

I – Gamma Knife Surgery.

C – Observation.

O – Time to tumour progression.

Question: When should we treat? now, or later?

Searchable Question (PICO)

Macquarie Neurosurgery 5

• Search for all studies that could provide data on gamma

knife surgery for residual pituitary adenoma

• Search Medline, Embase, and Scopus.

• Include case series and cohort studies.

• Exclude case reports.

Search Strategy

Macquarie Neurosurgery 6

Macquarie Neurosurgery 7

MEDLINE SEARCH

Macquarie Neurosurgery 8

EMBASE SEARCH

Macquarie Neurosurgery 9

SCOPUS SEARCH

Prisma

Macquarie Neurosurgery 10

Medline 81 Embase 34 Others 2

Total papers 151

(78 Duplicates)

Abstracts reviewed 34

Excluded 6

Articles retrieved 9

Excluded 25

Excluded 117

Articles reviewed 3

Scopus 112

Results

Macquarie Neurosurgery 11

Authors Year Journal Instit-

utions

Study Design No. Classifica-

tion

Tx. Follow

Up

Progress-

ion

RRIED RRIONI

Chen

et al

2012 Neuro-

endocrinology

China Systematic

Review

971 5 yrs

10 yrs

Nil 5 yrs

10 yrs

29%

41%

N/A N/A

Chen & Li

et al

2013 European

Journal of

Endocrinology

China Systematic

Review

925 < 2 ml

2-4 ml

> 4 ml

GKS 5-10

yrs

1%

4%

9%

1%

7%

22%

1%

0%

2%

Pomeraniec

et al

2016 Journal of

Neurosurgery

USA Retrospective

Cohort

64 < 6 m

> 6 m

GKS 4.8 yr

7 yr

6.3%

28.1%

16.7%

63.6%

N/A

Conclusions

Residual adenoma is likely to progress slowly over time with a tumourvolume doubling time (TVDT) in a few years.

Gamma knife surgery is effective in controlling progression of residual non-functioning pituitary adenoma.

The rate of radiosurgery induced endocrine deficit (RRIED) is higher when the residual tumour volume is larger.

The rate of radiosurgery induced optic neuropathy injury (RRIONI) is low.

Close follow-up and timely intervention is a reasonable choice for known residual post-op NFAs.

For large residual NFPAs, surgery is recommended to reduce residual tumour volume +/- GKS.Macquarie Neurosurgery 12