Evaluation of the outcomes of treating pituitary tumor by rotating gamma knife at the nuclear medicine and oncology center, bachmai hospital

Nội dung text: Evaluation of the outcomes of treating pituitary tumor by rotating gamma knife at the nuclear medicine and oncology center, bachmai hospital

1. Journal of military pharma-medicine no6-2017 EVALUATION OF THE OUTCOMES OF TREATING PITUITARY TUMOR BY ROTATING GAMMA KNIFE AT THE NUCLEAR MEDICINE AND ONCOLOGY CENTER, BACHMAI HOSPITAL Nguyen Thi Minh Phuong*; Mai Trong Khoa** Doan Van De***; Tran Quoc Hung* Summary Objectives: To evaluate treatment outcomes of rotating Gamma knife radiosurgery (RGKR) for pituitary adenomas at the Nuclear Medicine and Oncology Center, Bachmai Hospital. Subjects and methods: A prospective interventional study was conducted on 48 patients, who were treated with rotating Gamma knife for pituitary tumor. All patients had size of tumor < 5 cm on MRI and recruited in between April, 2008 and April, 2016. Results: Male/female ratio was 1/2, patient age ranged from 21 - 78 years old with median of 44.58 ± 12.84 years old. Clinical symptoms were reduced gradually after radiosurgery: the percentage of patients with headache symptom at baseline after the time of 6 months, 12 months, 24 months and 36 months accounted for 70.8%, 50%, 36.4%, 20.5% and 8.6%, respectively. Abnormal hormone level had been improved after radiosurgery. Size of the tumor was reduced. Severe side effects or death were not reported in the follow-up period. Conclusion: Radiosurgery with rotating Gamma knife is an effective and safe treatment method for pituitary tumor. * Keywords: Pituitary tumor; Rotating Gamma knife; Outcomes. INTRODUCTION treatment of pituitary tumors are available The pituitary gland tumors are tumors such as surgery, medicine, radiation therapy, that occur in the anterior pituitary, which and radiotherapy by rotating Gamma account for 10 - 15% of the intracranial knife. The main purpose of these methods tumors, more than 99% of the pituitary is to remove or inhibit tumor growth, to tumors are benign tumors and grow maintain the endocrine function of the slowly. Pituitary tumors are mainly seen in pituitary gland, to suppress or reduce the adults, very rarely seen before puberty, secretion of hormones caused by tumors, and the incidence rate of men compared and with minimum of invasion to the to women is 1/2. Different methods for surrounding areas. In previous decades, * 198 Hospital ** Bachmai Hospital *** 103 Hospital Conresponding author: Nguyen Thi Minh Phuong (drminhphuong198@gmail.com) Date received: 20/04/2017 Date accepted: 25/07/2017 169
2. Journal of military pharma-medicine n o6-2017 treatment of pituitary tumors was mainly * Exclusion criteria: with medications. When medical treatment - Patients with other endocrine diseases fails, surgery may be performed to open such as Basedow disease, adrenal tumors... the cranium but it was done only in some - Patients taking prolonged steroids, major hospitals with high rate of postoperative pregnant women, breast-feeding women. complications and the mortality rate over 10%. In recent decades, surgical removal - Patients < 18 years old. of the tumor by endoscopy through the 2. Research methods. sinus fracture has partially reduced the mortality rate [1, 2] but the rate of Interventional study with repeated- recurrence after surgery is still high. measures analysis. Globally, the application of rotating Gamma * Study procedures: knife for treatment is widely accepted in - Baseline evaluations: the United States, Japan, Singapore, France, Hungary... [3, 4, 5, 6]. Since 2007, the + Record clinical and laboratory information American rotating Gamma knife system in study case report forms. has been introduced at the Center for + Clinical: functional and physical Nuclear Medicine and Oncology, Bachmai symptoms. Hospital for the treatment of brain tumors + Para-clinical tests: hormone levels, and some cranial diseases including pituitary size and nature of tumors on brain MRI. tumors. This treatment method is less - Steps for conducting the operation: invasive, requires no anesthesia, with less complication rate and short hospital stay. + Step 1: prepare the patient. In Vietnam, there has been no studies + Step 2: fix the patient's head using evaluating the role of rotating Gamma the Fraim frame. knife for the treatment of pituitary tumors. + Step 3: MRI simulation. Therefore, this study aims to: Evaluate + Step 4: plan the radiosurgery. the treatment results of pituitary tumors by rotating Gamma knife at the Center of + Step 5: proceed with radiotherapy. Nuclear Medicine and Oncology, Bachmai - Post-treatment evaluation: based on Hospital. clinical and paraclinical symptoms of the SUBJECTS AND METHODS patient being examined, compared before and after treatment. 1. Subjects. + Clinical characteristics: age, sex, history * Inclusion criteria: of treatment, clinical symptoms before The study enrolled 48 patients aged treatment and 6 months, 12 months, 24 ≥ 18 years diagnosed with pituitary tumor months and 36 months after treatment. based on cranial MRI and treated with rotating Gamma knife at the Center for + Clinical features: Nuclear Medicine and Oncology, Bachmai . Evaluation of size, nature and extent Hospital from April, 2008 to April, 2016. of invasive on MRI before treatment, 170
3. Journal of military pharma-medicine no6-2017 6 months, 12 months, 24 months, 36 months RESULTS AND DISCUSSIONS after treatment. 1. Patient disposition by age group. . Hormonal tests: PRL, GH, ACTH, LH, 18 - 30 years old: 4 patients (8.3%); TSH, FSH before treatment, 6 months, 31 - 45 years old: 21 patients (43.8%); 12 months, 24 months, 36 months after 46 - 60 years old : 16 patients (33.3%); treatment. > 60 years old: 7 patients (14,6%). + Patients underwent pituitary hormone The study on 48 patients with pituitary quantification using morning venous blood tumors using rotating Gamma radiography (fasting condition). at the Center for Nuclear Medicine and + Investigation of TSH, FSH, PRL, ACTH, Oncology, Bachmai Hospital showed that: LH, GH... by electrochemistry immunoassay The majority of patients in the age group on Elecsys 2010 with Roche reagent at of 31 - 45 years old, the lowest age was Biochemistry Department, Bachmai Hospital. 21, the highest age was 78, the average * Data analysis and processing: was 44.58 ± 12.84 years old. The percentage The collected information is encrypted of male accounted for 33.3%; females and processed on SPSS 16.0 software. accounted for 66.7%. 2. Distribution of patients by gender. Figure 1: Patient distribution. In the study group, the proportion of (62.5%); surgical interventions : 12 patients male patients was 33.3% male, female (25.0%). was 66.7%. Heng Wan's study (2007) [3] Most patients have received medication reported that the average age of patients or surgical treatment for recurrence. 12.5% with pituitary tumors was 44.58 ± 12.84 of the patients who received no treatment years old and the proportion of women was higher than men. were indicated to use radiotherapy. According to Faglia G, 92% of patients 3. Medical history before surgery. with pituitary gland tumors who had been No interventions: 6 patients ( 12.5%); treated with Gamma irradiation had failed medication interventions : 30 patients to response to prior medication treatments. 171
4. Journal of military pharma-medicine n o6-2017 4. Irradiation dosages. Table 1: Dose (Gy) Standard deviation Mean dose (X) Min Max p Group (SD) Gamma knife group (n = 48) 13.6 2.2 11 22 Hormonally active (n = 21) 14.0 2.9 11 22 > 0.05 Clinically non-functioning 13.3 1.3 12 16 (n = 27) The mean surgical irradiation dose of 13.6 ± 2.2 Gy. The dose was used in the hormonally active group was higher than that in the hormonally non-active group, but the difference was not statistically significant (p > 0.05). 5. Time to follow-up after surgery. Table 2: Follow-up time (month) Value Mean (X ± SD) 38.9 ± 10.9 Minimum 12 Maximum 63 The mean postoperative follow-up time was 38.9 ± 10.9 months (from 12 months to 63 months) after radiosurgery. We found that all of the clinical signs of postoperative irradiation were significantly improved. 6. Clinical symptoms before and after the radiosurgery. Table 3: Baseline 6 months 12 months 24 months 36 months Symptoms (n = 48) (n = 46) (n = 44) (n = 39) (n = 35) (n = 48) n % n % n % n % n % Headache 34 70.8 23 50 16 36.4 8 20.5 3 8.6 Visual disturbance 25 52.1 17 37.0 10 22.7 7 17.9 6 17.1 Libido 6 12.5 6 13.3 2 4.4 2 4.8 1 2.7 Menstrual disorder 10 20.8 11 23.9 5 11.4 5 12.5 4 11.4 Lactation 8 16.7 6 13.0 2 4.5 2 5.1 0 0 Clinical symptoms decreased over time. Headache was one of the most common symptoms before treatment (70.8% of patients) and this had decreasead to 50%, 36.4%, 20.5%, and 8.6% after 6, 12, 24, and 36 months, respectively. The study on 172
5. Journal of military pharma-medicine no6-2017 over 270 patients of Sheehan J.P (2011) [5] showed that rotating Gamma kife treatment improved functional symptoms in 90% of patients and 55% of them improved their physical symptoms. 7. Tumor size (on MRI) before and after the radiosurgery. Table 4: Baseline 6 months 12 months 24 months 36 months Time-points (n = 48) (n = 46) (n = 44) (n = 39) (n = 35) Mean tumor size (mm) 20.9 ± 10.3 19.5 ± 11.5 15.6 ± 12.3 12.9 ± 12.7 12.9 ± 12.4 Minimum tumor size (mm) 7 0 0 0 0 Maximum tumor size (mm) 48 48 48 50 50 Mean tumor size decreased after treatment, significantly decreased after 12 months compared with pretreatment, difference was statistically significant (p < 0,05). Heng Wan et al (2002) [3] showed that the percentage of patients with tumor size decreased or remained constant after tumor resection was 89.7%. 8. Hormone level before and after treatment. Table 5: Baseline 36 months after treatment Hormon level Mean SD Medium Mean SD Medium TSH (uU/mL) 3.647 14.224 1.500 1.941 1.141 1.840 LH (mU/mL) 5.97 2.72 5.42 6.09 2.75 5.49 FSH (mU/mL) 10.92 15.55 7.02 8.63 7.61 6.72 Prolactin (ng/mL) 62.27 115.03 12.45 29.99 75.78 13.42 GH (ng/mL) 11.31 24.38 2.35 2.83 1.95 2.19 ACTH (Pg/mL) 27.04 18.95 20.97 25.62 9.81 23.41 The post-treatment hormone levels decreased, especially PRL and GH, these levels significantly decreased and difference was statistically significant (p < 0.01). LH, ACTH, THS and FSH levels were not significantly reduced (p > 0.05). This was probably due to the fact that the number of patients with ACTH, TSH, LH and FSH hypersecretion was not significant. Shota Tanaka et al (2010) [6] reported that after the radiotherapy, the PRL concentration decreased from 88.4 ng/mL to 28.4 ng/mL. The difference was statistically significant (p = 0.001). There was no cases of death after treatment. 173
6. Journal of military pharma-medicine n o6-2017 CONCLUSION ph ẫu thu ật u tuy ến yên t ăng ti ết prolactin. Lu ận v ăn Tốt nghi ệp Bác s ỹ Nội trú Chuyên The study on 48 patients with pituitary ngành Ngo ại khoa. Trường Đạ i h ọc Y Hà N ội. tumors using rotating Gamma radiosurgery 2012. at the Center for Nuclear Medicine and Oncology, Bachmai Hospital: 2. Lý Ng ọc Liên. Nghiên c ứu áp d ụng ph ươ ng pháp m ổ u tuy ến yên qua đường - Patient age ranged from 21 - 78 years xoang b ướm t ại B ệnh vi ện Vi ệt Đứ c t ừ 2000 - old with average of 44.58 ± 12.84 years old. 2002. Lu ận v ăn T ốt nghi ệp Bác s ỹ Chuyên - Male/female ratio was 1/2. khoa C ấp II. Đạ i h ọc Y Hà N ội. 2003. - Clinical symptoms were reduced 3. Heng Wan. Gamma knife radiosurgery gradually after radiosurgery: the percentage for secretory pituitary adenomas: experience of patients with headache symptom at the in 347 consecutive cases. 2007, 106 (6), time point of baseline, after 6 months, 12 pp.980-987. months, 24 months, 36 months accounted 4. Faglia G. Genesis of pituitary adenomas, for 70.8%, 50%, 36.4%, 20.5% and 8.6%, in Landolt A Vance M.L, Reilly P.L. Pituitary respectively. adenoma. New York, Churchill Livingstone. - Abnormal hormone level GH, PRL 1996. had been improved after radiosurgery. 5. Sheehan J.P, Pouratian N, Steiner L, - Size of the tumor was reduced. Laws E.R, Vance M.L. Gamma knife surgery - Severe side effects or death were not for pituitary adenomas. Factors related reported in the follow-up period. to radiological and endocrine outcomes. - Radiosurgery with rotating Gamma Department of Neurological Surgery, University knife has been shown as an effective and of Virginia Health System, Charlottesville, safe treatment method for pituitary tumor. Virginia 22908, USA. jps2f@virginia.edu . 2011. 6. Shota Tanaka1, Michael J.Link. Gamma REFERENCES knife radiosurgery for patients with prolactin- 1. Nguy ễn Đứ c Anh. Nh ận xét đặ c điểm secreting pituitary adenomas. World Neurosurgery. lâm sàng, c ận lâm sàng và đánh giá k ết qu ả 2010, 74 (1), pp.147-152. 174