Stereotactic radiosurgery for metastatic tumors in the pituitary gland and the cavernous sinus

2006 ◽  
Vol 105 (Supplement) ◽  
pp. 37-42 ◽  
Author(s):  
Yoshimasa Mori ◽  
Tatsuya Kobayashi ◽  
Yuta Shibamoto
Keyword(s):  
Pituitary Gland ◽  
Stereotactic Radiosurgery ◽  
Cavernous Sinus ◽  
Cranial Nerves ◽  
Spatial Relationship ◽  
Visual Disturbance ◽  
Brain Parenchyma ◽  
Dose Selection ◽  
Nasal Cancer ◽  
Radiation Side Effects

ObjectMetastases to the pituitary gland and cavernous sinus occasionally occur. Metastases of this nature are problematic because they are adjacent to eloquent structures such as cranial nerves, including the optic pathways and nerves for extraocular movement and facial sensation. Stereotactic radiosurgery has been reported to be safe and effective for metastases in various sites of brain parenchyma, providing the tumors are not large. Radiosurgery can be performed to treat a precisely defined target, and the risk of radiation side effects on the surrounding structures is reduced. The results of Gamma Knife surgery (GKS) for the treatment of metastases in the pituitary gland and the cavernous sinus are evaluated.MethodsAmong 623 patients with brain metastases treated by GKS, 13 patients (2.1%) had pituitary and/or cavernous metastases. The primary malignancies included lung cancer (five cases), breast cancer (two cases), parotid cancer (two cases), renal cell carcinoma, thyroid cancer, nasal cancer, and gastrointestinal stromal tumor (one case each). The location of the tumors was the pituitary gland (Type 1) in four patients, the cavernous sinus (Type 2) in five patients, and both the cavernous sinus and the sellar region (Type 3) in four patients. The patients' symptoms included dysfunction of the pituitary gland (two patients), visual disturbance (four patients), oculomotor palsy (one patient), abducent palsy (five patients), and trigeminal dysfunction (five patients). A margin dose of 12 to 12.3 Gy was delivered to pituitary metastases. A margin dose of 14.4 to 20 Gy was delivered to cavernous lesions. The dose selection depended on the spatial relationship between tumors and the cranial nerves. Imaging and clinical follow-up data have been obtained in nine of 13 patients for 2 to 12 months (median 4 months) after GKS. Three pituitary and/or cavernous tumors are stable in size, and six tumors have disappeared or decreased in size; full or partial improvement of visual function, extraocular movement, and facial sensation have been achieved in these six patients.Conclusions These preliminary results seem to indicate that GKS is a safe and effective treatment for pituitary and cavernous metastases, as it is effective for parenchymal metastases and promptly improved some patients' symptoms.

Dose—response tolerance of the visual pathways and cranial nerves of the cavernous sinus to stereotactic radiosurgery

1998 ◽  
Vol 88 (1) ◽  
pp. 43-50 ◽  
Author(s):  
Klaus A. Leber ◽  
Jutta Berglöff ◽  
Gerhard Pendl
Keyword(s):  
Stereotactic Radiosurgery ◽  
Cavernous Sinus ◽  
Dose Response ◽  
Cranial Nerves ◽  
Visual Pathways ◽  
Content Type ◽  
Number Of Patients ◽  
Response Tolerance ◽  
Fine Print

As the number of patients treated with stereotactic radiosurgery increases, it becomes particularly important to define with precision adverse effects on distinct structures of the nervous system. Object. This study was designed to assess the dose—response tolerance of the visual pathways and cranial nerves after exposure of the cavernous sinus to radiation. Methods. A total of 66 sites in the visual system and 210 cranial nerves of the middle cranial fossa were investigated in 50 patients who had undergone gamma knife treatment for benign skull base tumors. The mean follow-up period was 40 months (range 24–60 months). Follow-up examinations consisted of neurological, neuroradiological, and neuroophthalmological evaluations. The actuarial incidence of optic neuropathy was zero for patients who received a radiation dose of less than 10 Gy, 26.7% for patients receiving a dose in the range of 10 to less than 15 Gy, and 77.8% for those who received doses of 15 Gy or more (p < 0.0001). Previously impaired vision improved in 25.8% and was unchanged in 51.5% of patients. No sign of neuropathy was seen in patients whose cranial nerves of the cavernous sinus received radiation doses of between 5 and 30 Gy. Because tumor control appeared to have been achieved in 98% of the patients, the deterioration in visual function cannot be attributed to tumor progression. Conclusions. The structures of the visual pathways (the optic nerve, chiasm, and tract) exhibit a much higher sensitivity to single-fraction radiation than other cranial nerves, and their particular dose—response characteristics can be defined. In contrast, the oculomotor and trigeminal nerves have a much higher dose tolerance.

Endocrinological outcome after pituitary transposition (hypophysopexy) and adjuvant radiotherapy for tumors involving the cavernous sinus

2011 ◽  
Vol 115 (1) ◽  
pp. 55-62 ◽  
Author(s):  
Philipp Taussky ◽  
Ricky Kalra ◽  
Jeroen Coppens ◽  
Jahan Mohebali ◽  
Randy Jensen ◽  
...  
Keyword(s):  
Pituitary Gland ◽  
Stereotactic Radiosurgery ◽  
Cavernous Sinus ◽  
Stereotactic Radiotherapy ◽  
Pituitary Adenomas ◽  
Residual Tumor ◽  
Fractionated Stereotactic Radiotherapy ◽  
Normal Pituitary Gland ◽  
Radiotherapy Treatment

Object Stereotactic radiosurgery and fractionated stereotactic radiotherapy are commonly used in the treatment of residual or recurrent benign tumors of the skull base and cavernous sinus. A major risk associated with radiosurgical or radiotherapy treatment of residual or recurrent tumors adjacent to normal functional pituitary gland is radiation of the pituitary, which frequently leads to the development of hypopituitarism. The authors have used a technique of pituitary transposition to reduce the radiation dose to the normal pituitary gland in cases of planned radiosurgical treatment of residual tumor within the cavernous sinus. Here, the authors analyze the long-term endocrinological outcomes in patients with residual and recurrent tumors who undergo hypophysopexy and adjuvant radiosurgical or conformal fractionated radiotherapy treatment. Methods Pituitary transposition involves placement of a fat graft between the normal pituitary gland and residual tumor in the cavernous sinus. A sellar exploration for tumor resection is performed, the pituitary gland is transposed from the region of the cavernous sinus, and the graft is interposed between the pituitary gland and the residual tumor. The residual tumor may then be treated with stereotactic radiosurgery or conformal fractionated radiation therapy. The authors evaluated endocrinological outcome, safety of the procedure, and postoperative complications in patients who underwent this procedure during a 7-year period. Results Hypophysopexy has been used in 34 patients with nonfunctioning pituitary adenomas (19), functional pituitary adenomas (8), chordomas (2), meningiomas (2), chondrosarcoma (1), hemangiopericytoma (1), or hemangioma (1) involving the sella and cavernous sinus. Follow-up (radiographic and endocrinological) has been performed yearly in all patients. Two patients experienced postoperative endocrine deficits before radiosurgery (1 transient), but none of the patients developed new hypopituitarism during the median 4-year follow-up (range 1–8 years) after radiosurgery or fractionated stereotactic radiotherapy. Conclusions The increased distance between the normal pituitary gland and the residual tumor facilitates treatment of the tumor with radiosurgery or radiotherapy and effectively reduces the incidence of radiation injury to the normal pituitary gland when compared with historical controls.

scholarly journals SUN-286 Lymphocytic Hypophysitis Mimicking Tolosa Hunt Syndrome

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Ma Dolores Del Castillo ◽  
Knarik Arkun ◽  
Mina Safain ◽  
Ronald M Lechan
Keyword(s):  
Carotid Artery ◽  
Pituitary Gland ◽  
Cavernous Sinus ◽  
Cranial Nerves ◽  
Granulomatous Inflammation ◽  
Lymphocytic Hypophysitis ◽  
Systemic Autoimmune Disease ◽  
Free T4 ◽  
Hunt Syndrome ◽  
Work Up

Abstract Introduction: Lymphocytic hypophysitis often presents with headache, hypopituitarism and visual disturbance, the latter from optic nerve compression. Rarely, it can present with diplopia from cranial nerves III, IV and VI (3.7%) and cavernous sinus involvement (1). Clinical Case: A 40 year old woman presented with left eye pain, blurry vision, ptosis and diplopia for 2 days, preceded by headache for 2 weeks. Exam was remarkable for left eye ptosis, mild proptosis, downward and outward gaze and inability to adduct her left eye. Endocrinological exam revealed free T4 0.67 ng/dL (Nl 0.70 - 1.48), TSH 0.67 ng/dL (Nl 0.70–1.48), estradiol &lt;10 pg/mL, LH 1.0 mIU/mL, FSH 6.9 mIU/mL, prolactin 23.3 ng/ml (Nl 5.2–26.5) and IGF-1 95 ng/mL (Nl 52–328). Cortisol was not assessed as patient was already on steroids. Work-up revealed atypical ANCA (1:320) but normal C-ANA (&lt;1:20), P-ANCA (&lt;1:20), and the rest of immune work-up was negative including ACE, ESR, CRP, ANA, serine protease and myeloperoxidase. No systemic manifestations were present concerning for systemic autoimmune disease. CSF exam was unrevealing including a normal ACE level. MRI revealed an enlarged pituitary gland with suprasellar extension containing a focal area of T2 hyperintensity and slight T2 hypointensity at the posterior aspect of the gland. There was a midline, thickened infundibulum, enhancement of both cavernous sinuses and narrowing of right internal carotid artery without occlusion. Endoscopic endonasal transsphenoidal biopsy of pituitary lesion confirmed diagnosis of lymphocytic hypophysitis and did not meet criteria for IgG4 hypophysitis. After 4 weeks of prednisone, she had significant symptomatic improvement and repeat MRI showed decreased pituitary size but persistent abnormal enhancement of the pituitary gland and cavernous sinuses. Conclusion: The atypical and variable clinical and radiological findings of lymphocytic hypophysitis can mimic other inflammatory, infiltrative lesions, pituitary tumor with apoplexy and Tolosa Hunt Syndrome. Tolosa Hunt syndrome is an idiopathic granulomatous inflammation of the cavernous sinus involving cranial nerves II to VI and often presenting with painful ophthalmoplegia. Pituitary involvement and carotid artery narrowing have been observed (2). Our case highlights a patient with cranial nerve III palsy and significant cavernous sinus involvement, clinically concerning for Tolosa Hunt syndrome, but confirmed by biopsy to be lymphocytic hypophysitis. There are no specific serum markers to distinguish lymphocytic hypophysitis from other entities and when uncertain, diagnosis is best established by biopsy. References: 1 Caturegli P, et al. Autoimmune hypophysitis. Endocr Rev 2005, 26: 599–614. 2 A. Kambe et al. A case of Tolosa-Hunt syndrome affecting both cavernous sinuses and hypophysis and associated C3 and C4 aneurysms. Surgical Neurology 65 (2006) 304–307.

Cavernous sinus compartments from the endoscopic endonasal approach: anatomical considerations and surgical relevance to adenoma surgery

2018 ◽  
Vol 129 (2) ◽  
pp. 430-441 ◽  
Author(s):  
Juan C. Fernandez-Miranda ◽  
Nathan T. Zwagerman ◽  
Kumar Abhinav ◽  
Stefan Lieber ◽  
Eric W. Wang ◽  
...  
Keyword(s):  
Cavernous Sinus ◽  
Cranial Nerves ◽  
Spatial Relationship ◽  
Abducens Nerve ◽  
Human Head ◽  
Residual Tumor ◽  
Surgical Anatomy ◽  
Endoscopic Endonasal Approach ◽  
Endonasal Approach ◽  
Endoscopic Endonasal

OBJECTIVETumors with cavernous sinus (CS) invasion represent a neurosurgical challenge. Increasing application of the endoscopic endonasal approach (EEA) requires a thorough understanding of the CS anatomy from an endonasal perspective. In this study, the authors aimed to develop a surgical anatomy–based classification of the CS and establish its utility for preoperative surgical planning and intraoperative guidance in adenoma surgery.METHODSTwenty-five colored silicon–injected human head specimens were used for endonasal and transcranial dissections of the CS. Pre- and postoperative MRI studies of 98 patients with pituitary adenoma with intraoperatively confirmed CS invasion were analyzed.RESULTSFour CS compartments are described based on their spatial relationship with the cavernous ICA: superior, posterior, inferior, and lateral. Each compartment has distinct boundaries and dural and neurovascular relationships: the superior compartment relates to the interclinoidal ligament and oculomotor nerve, the posterior compartment bears the gulfar segment of the abducens nerve and inferior hypophyseal artery, the inferior compartment contains the sympathetic nerve and distal cavernous abducens nerve, and the lateral compartment includes all cavernous cranial nerves and the inferolateral arterial trunk. Twenty-nine patients had a single compartment invaded, and 69 had multiple compartments involved. The most commonly invaded compartment was the superior (79 patients), followed by the posterior (n = 64), inferior (n = 45), and lateral (n = 23) compartments. Residual tumor rates by compartment were 79% in lateral, 17% in posterior, 14% in superior, and 11% in inferior.CONCLUSIONSThe anatomy-based classification presented here complements current imaging-based classifications and may help to identify involved compartments both preoperatively and intraoperatively.

Long-term disease control and treatment outcomes of stereotactic radiosurgery in cavernous sinus meningiomas

2021 ◽  
Author(s):  
Rafael Martinez-Perez ◽  
William Florez-Perdomo ◽  
Lindsey Freeman ◽  
Timothy H. Ung ◽  
A. Samy Youssef
Keyword(s):  
Disease Control ◽  
Treatment Outcomes ◽  
Stereotactic Radiosurgery ◽  
Cavernous Sinus

scholarly journals Image-Guided Multisession Radiosurgery of Skull Base Meningiomas

Cancers ◽  
2020 ◽  
Vol 12 (12) ◽  
pp. 3569
Author(s):  
Alfredo Conti ◽  
Antonio Pontoriero ◽  
Giuseppe Iatì ◽  
Salvatore M. Cardali ◽  
Anna Brogna ◽  
...  
Keyword(s):  
Skull Base ◽  
Stereotactic Radiosurgery ◽  
Cranial Nerves ◽  
Progression Free Survival ◽  
Motor Deficits ◽  
Intracranial Meningioma ◽  
Treatment Schedule ◽  
Fractionated Radiotherapy ◽  
Patient Reported ◽  
Skull Base Meningiomas

Background: The efficacy of single-session stereotactic radiosurgery (sSRS) for the treatment of intracranial meningioma is widely recognized. However, sSRS is not always feasible in cases of large tumors and those lying close to critically radiation-sensitive structures. When surgery is not recommended, multi-session stereotactic radiosurgery (mSRS) can be applied. Even so, the efficacy and best treatment schedule of mSRS are not yet established. The aim of this study is to validate the role of mSRS in the treatment of skull base meningiomas. Methods: A retrospective analysis of patients with skull base meningiomas treated with mSRS (two to five fractions) at the University of Messina, Italy, from 2008 to 2018, was conducted. Results: 156 patients met the inclusion criteria. The median follow-up period was 36.2 ± 29.3 months. Progression-free survival at 2-, 5-, and 10- years was 95%, 90%, and 80.8%, respectively. There were no new visual or motor deficits, nor cranial nerves impairments, excluding trigeminal neuralgia, which was reported by 5.7% of patients. One patient reported carotid occlusion and one developed brain edema. Conclusion: Multisession radiosurgery is an effective approach for skull base meningiomas. The long-term control is comparable to that obtained with conventionally-fractionated radiotherapy, while the toxicity rate is very limited.

Zygomatic Approach to Cavernous Sinus Chordoma: 2-Dimensional Operative Video

2021 ◽  
Author(s):  
Antonio Aversa ◽  
Ossama Al-Mefty
Keyword(s):  
Carotid Artery ◽  
Cavernous Sinus ◽  
Infratemporal Fossa ◽  
Cranial Nerves ◽  
Radical Resection ◽  
High Rate ◽  
Petrous Apex ◽  
High Dose ◽  
Middle Fossa ◽  
Cavernous Carotid Artery

Abstract Chordoma is not a benign disease. It grows invasively, has a high rate of local recurrence, metastasizes, and seeds in the surgical field.1 Thus, chordoma should be treated aggressively with radical resection that includes the soft tissue mass and the involved surrounding bone that contains islands of chordoma.2–5 High-dose radiation, commonly by proton beam therapy, is administered after gross total resection for long-term control. About half of chordoma cases occupy the cavernous sinus space and resecting this extension is crucial to obtain radical resection. Fortunately, the cavernous sinus proper extension is the easier part to remove and pre-existing cranial nerves deficit has good chance of recovery. As chordomas originate and are always present extradurally (prior to invading the dura), an extradural access to chordomas is the natural way for radical resection without brain manipulation. The zygomatic approach is key to the middle fossa, cavernous sinus, petrous apex, and infratemporal fossa; it minimizes the depth of field and is highly advantageous in chordoma located mainly lateral to the cavernous carotid artery.6–12 This article demonstrates the advantages of this approach, including the mobilization of the zygomatic arch alleviating temporal lobe retraction, the peeling of the middle fossa dura for exposure of the cavernous sinus, the safe dissection of the trigeminal and oculomotor nerves, and total control of the petrous and cavernous carotid artery. Tumor extensions to the sphenoid sinus, sella, petrous apex, and clivus can be removed. The patient is a 30-yr-old who consented for surgery.

The Medial Wall of the Cavernous Sinus: Microsurgical Anatomy

Neurosurgery ◽  
2004 ◽  
Vol 55 (1) ◽  
pp. 179-190 ◽  
Author(s):  
Alexandre Yasuda ◽  
Alvaro Campero ◽  
Carolina Martins ◽  
Albert L. Rhoton ◽  
Guilherme C. Ribas
Keyword(s):  
Pituitary Gland ◽  
Cavernous Sinus ◽  
Thin Sheet ◽  
Single Layer ◽  
Lateral Wall ◽  
The Body ◽  
Medial Wall ◽  
Microsurgical Anatomy ◽  
Pituitary Fossa ◽  
Adjacent Structures

Abstract OBJECTIVE: This study was conducted to clarify the boundaries, relationships, and components of the medial wall of the cavernous sinus (CS). METHODS: Forty CSs, examined under ×3 to ×40 magnification, were dissected from lateral to medial in a stepwise fashion to expose the medial wall. Four CSs were dissected starting from the midline to lateral. RESULTS: The medial wall of the CS has two parts: sellar and sphenoidal. The sellar part is a thin sheet that separates the pituitary fossa from the venous spaces in the CS. This part, although thin, provided a barrier without perforations or defects in all cadaveric specimens studied. The sphenoidal part is formed by the dura lining the carotid sulcus on the body of the sphenoid bone. In all of the cadaveric specimens, the medial wall seemed to be formed by a single layer of dura that could not be separated easily into two layers as could the lateral wall. The intracavernous carotid was determined to be in direct contact with the pituitary gland, being separated from it by only the thin sellar part of the medial wall in 52.5% of cases. In 39 of 40 CSs, the venous plexus and spaces in the CS extended into the narrow space between the intracavernous carotid and the dura lining the carotid sulcus, which forms the sphenoidal part of the medial wall. The lateral surface of the pituitary gland was divided axially into superior, middle and inferior thirds. The intracavernous carotid coursed lateral to some part of all the superior, middle, and inferior thirds in 27.5% of the CSs, along the inferior and middle thirds in 32.5%, along only the inferior third in 35%, and below the level of the gland and sellar floor in 5%. In 18 of the 40 CSs, the pituitary gland displaced the sellar part of the medial wall laterally and rested against the intracavernous carotid, and in 6 there was a tongue-like lateral protrusion of the gland that extended around a portion of the wall of the intracavernous carotid. No defects were observed in the sellar part of the medial wall, even in the presence of these protrusions. CONCLUSION: The CS has an identifiable medial wall that separates the CS from the sella and capsule of the pituitary gland. The medial wall has two segments, sellar and sphenoidal, and is formed by just one layer of dura that cannot be separated into two layers as can the lateral wall of the CS. In this study, the relationships between the medial wall and adjacent structures demonstrated a marked variability.

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