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CyberKnife robotic radiosurgery in the multimodal management of acromegaly patients with invasive macroadenoma: a single center’s experience

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Abstract

Surgery is the primary treatment for acromegaly. However, surgery may not be curative of some tumors, particularly invasive macroadenomas. Adjuvant radiation, specifically robotic stereotactic radiosurgery (rSRS), may improve the endocrine outcome. We retrospectively reviewed hormonal and radiological data of 22 acromegalic patients with invasive macroadenomas treated with rSRS at Stanford University Medical Center between 2000 and 2016. Prior to treatment, the tumor’s median maximal diameter was 19 mm (2.5–50 mm). Cavernous sinus invasion occurred in 19 patients (86.3%) and compression of the optic chiasm in 2 (9.0%). At last follow up, with an average follow up of 43.2 months, all patients had a reduction in their IGF-1 levels (median IGF-1% upper limit of normal (ULN) baseline: 136% vs last follow up: 97%; p = 0.05); 9 patients (40.9%) were cured, and 4 (18.1%) others demonstrated biochemical control of acromegaly. The median time to cure was 50 months and the mean interval to cure or biochemical control was 30.3 months (± 24 months, range 6–84 months). Hypopituitarism was present in 8 patients (36.3%) and new pituitary deficits occurred in 6 patients with a median latency of 31.6 ± 14.5 months. At final radiologic follow-up, 3 tumors (13.6%) were smaller and 19 were stable in size. The mean biologically effective dose (BED) was higher in subjects cured compared to those with persistent disease, 163 Gy3 (± 47) versus 111 Gy3 (± 43), respectively (p = 0.01). No patient suffered visual deterioration. Robotic SRS is a safe and effective treatment for acromegaly: radiation-induced visual complications and hypopituitarism is rare.

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Abbreviations

ACTH:

Adrenocorticotropic hormone

BED:

Biologically effective dose

CK:

CyberKnife

CT:

Computerized tomography

DA:

Dopamine agonists

Dmax:

Maximum dosimetry

SD:

Standard deviation

EQD2:

2 Gray equivalent dose

FSH:

Follicle stimulating hormone

GH:

Growth hormone

GK:

Gamma knife

Gy:

Gray

IGF1:

Insulin-like growing factor 1

IRB:

Institutional review board

LH:

Luteinizing hormone

MRI:

Magnetic resonance imaging

mRS:

Modified rankin scale

PEG:

GH-receptor antagonist

rSRS:

Robotic stereotactic radiosurgery

SRT:

Stereotactic radiotherapy

SRLs:

Somatostatin-receptor ligands

T4:

Thyroxine

TSH:

Thyroid stimulating hormone

ULN:

Upper limit of the normal range

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Funding

This work was supported by NIH/NCRR (REDCap Grant Support UL1 TR001085).

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Author notes

  1. Elisa Sala and Justin M. Moore have contributed equally to this work and are co-first authors on this manuscript.

Authors and Affiliations

  1. Unit of Endocrinology, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, University of Milan, Milan, Italy

    Elisa Sala

  2. Department of Neurological Surgery, Stanford Medical Center, Stanford University, Palo Alto, CA, USA

    Elisa Sala, Justin M. Moore, Alvaro Amorin, Hector Martinez Jr., Aprotim C. Bhowmik, Layton Lamsam, Laurence Katznelson & Griffith R. Harsh

  3. Department of Radiation Oncology, Stanford Medical Center, Stanford University, Palo Alto, CA, USA

    Steven Chang & Scott G. Soltys

  4. Department of Medicine, Stanford Medical Center, Stanford University, Palo Alto, CA, USA

    Laurence Katznelson

  5. Stanford School of Medicine, 875 Blake Wilbur Drive, Stanford, CA, 94305-5821, USA

    Griffith R. Harsh

Authors
  1. Elisa Sala
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  2. Justin M. Moore
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  3. Alvaro Amorin
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  9. Laurence Katznelson
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Correspondence to Griffith R. Harsh.

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Sala, E., Moore, J.M., Amorin, A. et al. CyberKnife robotic radiosurgery in the multimodal management of acromegaly patients with invasive macroadenoma: a single center’s experience. J Neurooncol 138, 291–298 (2018). https://doi.org/10.1007/s11060-018-2793-9

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  • DOI: https://doi.org/10.1007/s11060-018-2793-9

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