Proton stereotactic radiotherapy for persistent adrenocorticotropin-producing adenomas.

Abstract

CONTEXT:

Radiation therapy is a potentially curative treatment for corticotroph adenomas refractory to surgery. Protons have an advantage over photons (x-rays) by depositing energy at the target with no exit dose, providing a lower dose to adjacent normal tissues. Until recently, proton stereotactic radiotherapy (PSR) was available at only two U.S. centers; use will increase as proton facilities are under development.

OBJECTIVE:

Our objective was to evaluate the efficacy and safety of PSR for persistent Cushing's disease (CD) and Nelson's syndrome (NS).

DESIGN:

This was a retrospective review of 38 patients (33 with CD and five with NS) treated between 1992 and 2005.

PARTICIPANTS:

All patients had transsphenoidal surgery without biochemical cure. Four had previous irradiation with photons. The patients with NS underwent bilateral adrenalectomy 29-228 months (median 40) before PSR.

INTERVENTION:

Single-fraction PSR was delivered at a median dose of 20 Cobalt Gray Equivalents (range 15-20) on 1 treatment day.

MAIN OUTCOME MEASURES:

Complete response (CR) was defined as sustained (> or =3 months) normalization of urinary free cortisol off medical therapy. CR in NS was based on normalization of plasma corticotropin.

RESULTS:

At a median follow-up of 62 months (range 20-136), CR was achieved in five patients (100%) with NS and 17 (52%) patients with CD. Among all patients with CR, median time to CR was 18 months (range 5-49). No secondary tumors were noted on follow-up magnetic resonance imaging scans, and there was no clinical evidence of optic nerve damage, seizure, or brain injury. There were 17 patients (52%) who developed new pituitary deficits.

CONCLUSIONS:

PSR is effective for patients with persistent corticotroph adenomas with low morbidity after a median follow-up of 62 months; longer follow-up is warranted for late radiation-related sequelae.

• Authors: Joshua H Petit, Beverly M K Biller, Torunn I Yock, Brooke Swearingen, John J Coen, Paul Chapman, Marek Ancukiewicz, Marc Bussiere, Anne Klibanski, Jay S Loeffler
• Journal: The Journal of clinical endocrinology and metabolism (J Clin Endocrinol Metab) Vol. 93 Issue 2 Pg. 393-9 (Feb 2008) ISSN: 0021-972X [Print] United States
• PMID: 18029460 (Publication Type: Journal Article)

Chemical References

• Hydrocortisone

Topics

• Adolescent
• Adult
• Female
• Humans
• Hydrocortisone (urine)
• Kaplan-Meier Estimate
• Magnetic Resonance Imaging
• Male
• Middle Aged
• Nelson Syndrome (surgery, urine)
• Pituitary ACTH Hypersecretion (surgery, urine)
• Proton Therapy
• Radiosurgery (methods)
• Remission Induction
• Retrospective Studies