CyberKnife Radiosurgery in the Multimodal Management of Patients with Cushing Disease

Justin M Moore; Elisa Sala; Alvaro Amorin; Hector Martinez Jr; Aprotim C Bhowmik; Steven D Chang; Scott G Soltys; Griffith R Harsh; Laurence Katznelson

doi:10.1016/j.wneu.2018.01.057

CyberKnife Radiosurgery in the Multimodal Management of Patients with Cushing Disease

World Neurosurg. 2018 Apr:112:e425-e430. doi: 10.1016/j.wneu.2018.01.057. Epub 2018 Jan 31.

Authors

Justin M Moore¹, Elisa Sala², Alvaro Amorin³, Hector Martinez Jr³, Aprotim C Bhowmik³, Steven D Chang³, Scott G Soltys⁴, Griffith R Harsh³, Laurence Katznelson⁵

Affiliations

¹ Department of Neurosurgery, Stanford Medical Center, Stanford University, Palo Alto, California, USA; Department of Medicine, Stanford Medical Center, Stanford University, Palo Alto, California, USA.
² Department of Medicine, Stanford Medical Center, Stanford University, Palo Alto, California, USA; Unit of Endocrinology and Diabetology, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.
³ Department of Neurosurgery, Stanford Medical Center, Stanford University, Palo Alto, California, USA.
⁴ Department of Radiation Oncology, Stanford Medical Center, Stanford University, Palo Alto, California, USA.
⁵ Department of Neurosurgery, Stanford Medical Center, Stanford University, Palo Alto, California, USA; Department of Medicine, Stanford Medical Center, Stanford University, Palo Alto, California, USA. Electronic address: katznels@stanford.edu.

PMID: 29355797
DOI: 10.1016/j.wneu.2018.01.057

Abstract

Background: Surgery is the primary treatment for Cushing disease. When surgery is unsuccessful in normalizing hypercortisolism, adjuvant radiation, such as stereotactic radiosurgery, may be useful to improve biochemical control.

Methods: This retrospective study included a cohort of consecutive patients treated with CyberKnife (CK) radiosurgery for active Cushing disease at Stanford Hospital and Clinics.

Results: As first-line treatment, all patients underwent transsphenoidal surgery with histologic demonstration of an adrenocorticotropic hormone-producing pituitary adenoma. CK was performed as adjuvant therapy for persistent or recurrent disease. The median time between surgery and CK was 14 ± 34 months. Before CK, median maximal diameter of tumors was 9 mm (range, 7-32 mm), with cavernous sinus invasion in all patients (100%) and abutment of the optic chiasm in 1 patient (14.2%). With an average follow-up of 55.4 months, normalization of hypercortisolism was achieved in 4 patients (57.1%): 2 patients (28.5%) achieved normalization of the hypothalamic-pituitary-adrenal axis without glucocorticoid replacement, and 2 patients developed hypoadrenalism (28.5%). The median time to biochemical remission was 12.5 months. Hypopituitarism occurred in only 1 patient (14.2%), and no patients had visual complications. Time between surgery and radiotherapy of <14 months was associated with a significantly improved biochemical remission rate (P = 0.02).

Conclusions: In a cohort of patients with Cushing disease, we demonstrate that CK is an effective treatment with rare complications.

Keywords: Cushing disease; CyberKnife; Pituitary; Robotic stereotactic radiosurgery.

MeSH terms

Adolescent
Adult
Aged
Female
Humans
Male
Neurosurgical Procedures
Pituitary ACTH Hypersecretion / radiotherapy*
Pituitary ACTH Hypersecretion / surgery
Radiosurgery / instrumentation*
Retreatment
Treatment Outcome