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SRS-ROSE CASE FOR PITUITARY ADENOMA

SRS-ROSE CASE FOR PITUITARY ADENOMA

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SRS-ROSE CASE FOR PITUITARY ADENOMA

  1. 1. ROSE CASE STEREOTAXY FOR PITUITARY ADENOMA RADIATION ONCOLOGY SIMULATION TO EXECUTION DR KANHU CHARAN PATRO MD,DNB[RADIATION ONCOLOGY],MBA,FAROI,PDCR,CEPC
  2. 2. HISTORY • 52 year male with no co morbidities • Had complaints of vomiting on July 2020 – Projectile type • Associated with reeling sensation of head and involuntary movements involving all four limbs • Not associated with headache/ blurring of vision • Admitted in hospital and evaluated
  3. 3. MRI Scan - Preop SEQUENCES FINDINGS MRI 1. 2.3 × 1.6 × 1.6 cm 2. Dumbbell shaped 3. Altered intensity lesion in sellar region 4. Extending into Suprasellar location 5. Pituitary gland not separated from lesion 6. Optic chiasm – compressed & superiorly displaced 7. Doubtful B/L Parasellar extension (R>L) with encasement of cavernous segment B/L ICA (R>L) CE MRI 1. Peripheral rim enhancement with irregular non enhancing area within the matrix of lesion - Necrosis
  4. 4. MRI – T1 Contrast
  5. 5. MRI – T2-NO CAVERNOUS SINUS INVOLVEMENT
  6. 6. MRI – T2 SAGITTAL SECTION Dumdbell shaped
  7. 7. MRI – T1 Contrast saggittal section ?APOPLEXY
  8. 8. MRI – T1 Contrast coronal section
  9. 9. PREOP HORMONE HORMONES LEVEL PROLACTIN 20.85 ng/ml CORTISOL 8.34 mcg/ml T4 1.04 ng/dl TESTOSTERONE 1.72 ng/ml FSH 1.88 mIU/ml
  10. 10. SURGERY • Patient underwent Endoscopic Trans sphenoid Excision on 09-10-2020 • Near total excision • Packed with packing material
  11. 11. Histopathology • Histopathology – F/S/O Pituitary Macro adenoma – Focal hemorrhage noted • Immunohistochemistry – Synaptophysin +VE , – Chromogranin +VE – Ki 67 – 2%
  12. 12. Investigations asked • MRI POST OP • VISUAL – ACUITY – FIELD
  13. 13. MRI PROTOCOL • MRI POST OP CONTRAST • FSPGR-ANATOMY • FATSAT T1- PACKING MATERIAL DISTINGUISH • DELAYED CONTRAST- NORMAL PTUITARY DISTINGUISH • T2- TO SEE CAVERNOUS SINUS INVOLVEMNET • 1MM • NO GAP • NO TILT • 512 X 512 MATRIX • NEUTRAL NECK • FOV SHOULD INCLUDE BODY CONTOUR NOSE, EYE AND SKULL
  14. 14. VISUAL ACUITY 2/26/2021 14
  15. 15. 2/26/2021 15
  16. 16. 2/26/2021 16
  17. 17. Visual assessment preop
  18. 18. Visual assessment post op
  19. 19. PREOP POSTOP VISUAL ACUITY LEFT Normal Normal VISUAL ACUITY RIGHT Normal Normal VISUAL FIELD LEFT Near normal 100% VISUAL FIELD RIGHT Near normal 100% Visual assessment
  20. 20. HORMONAL TREATMENT DETAILS 2/26/2021 20
  21. 21. ENDOCRINE EVALUATION 2/26/2021 21
  22. 22. POST OP HORMONE HORMONES LEVEL PROLACTIN 20.2ng/ml CORTISOL 10mcg/ml T4 2.4ng/dl
  23. 23. MRI - POSTOP SEQUENCES FINDINGS T1 & T2 1. Residual pituitary tissue 2. 16×11×7mm on Right side 3. 12×8×8mm on Left side 4. Bridging soft tissue is seen along the floor of sella 5. B/L Cavernous sinus – normal 6. Optic chiasm – 4mm away from tumor
  24. 24. FSPGR CONTRAST
  25. 25. T2 FLAIR NO CAVERNOUS INVOLVEMENT
  26. 26. Imaging conclusion • Residual diseases • No cavernous sinus involvement • No chiasm compression • No Parasellar extension • No Suprasellar extension • Chiasm tumor distance-4mm • Packing material seen IMAGING CONCLUSION
  27. 27. DIFFERENTIATING PACKING MATERIAL 2/26/2021 27
  28. 28. Imaging conclusion IDENTIFYING THE PACKING MATERIAL
  29. 29. 2/26/2021 29
  30. 30. 2/26/2021 30
  31. 31. • Contour the residual as GTV • Be relax at caudal site and lateral side • Do not include cavernous sinuses unless involved • Differentiate from packing material • CTV- Unnecessary unless it is an aggressive adenoma with potential areas of microscopic infiltration • PTV – 1mm to GTV 2/26/2021 31 TARGET DELINEATION
  32. 32. • While SCRT is suitable for the treatment of all pituitary tumours, irrespective of size, shape or proximity to critical normal tissue structures, • SRS is only suitable for treatment of small tumours away from the optic chiasm 2/26/2021 32 SCRT VS SRS
  33. 33. FSRT FOR PITUITARY • Stereotactic radiotherapy originally referred to radiotherapy treatment delivered to an intracranial target lesion that was located by stereotactic means in a patient immobilised in a neurosurgical stereotactic head frame. The improved patient immobilisation, more accurate • Tumour target localisation using cross-sectional image for treatment planning, and high precision radiation treatment delivery to the tumour target, enabled a reduction in the margins around the radiotherapy target volume (the GTV to PTV margin), therefore achieving greater sparing of surrounding normal tissues than can be obtained with standard CRT techniques 2/26/2021 33
  34. 34. SCRT VS SRT • While SCRT is suitable for the treatment of all pituitary tumours, irrespective of size, shape or proximity to critical normal tissue structures, • SRS is only suitable for treatment of small tumours away from the optic chiasm 2/26/2021 34
  35. 35. IRSA Algorithm
  36. 36. IRSA Algorithm
  37. 37. Tumor board decision • After group discussion with neurosurgeon, radiation oncologist and patient, board decided to plan for stereotactic radiotherapy • Patient was explained about complications and outcome of each procedure
  38. 38. Patient discussion • Discussed about RT comparing with re-surgery • Discussed about the procedure • Discussed about visual preservation • Discussed about follow up imaging ,hormonal and visual evaluation • Discussed about tumor response • Discussed about need of surgery in future • Discussed about need of RERT in future • Discussed about post radiotherapy cyst formation • Discussed about post radiotherapy hypopituitarism and need of hormonal replacement
  39. 39. Dose selection
  40. 40. Dose selection • Hypo fractionated SRT with a dose of 21Gy / 3# or 25Gy / 5# showed – 98% Local control rate – 1% Visual disorder – 3% Hypopituitarism
  41. 41. • Planned for FSRT • Plan multiple fraction • 25Gy/5# - marginal dose Radiation tumor board
  42. 42. Immobilization and set up
  43. 43. • 1mm slice • Contrast • Vertex to neck • With fraxion Planning CT
  44. 44. MRI protocol • T1/T2/FLAIR sequence- Usual sequence • 3D FSPGR sequence- Normal anatomy • FATSAT sequence- Differentiate packing material • 512x 512 matrix • 1mm slice • No gap • No tilt • Neutral neck • FOV should include body contour nose, eye and skull
  45. 45. IMAGE FUSION 1. Soft tissue extension 2. Delineating optic apparatus 3. Differentiating packing material 4. Differentiating cavernous sinus from tumor 2/26/2021 45
  46. 46. • CT AND MRI FUSION Image fusion
  47. 47. • GTV delineation • VOLUME- 1.106 cc • Multiplanar evaluation Target delineation
  48. 48. • 1mm • VOLUME- 2.456 CC PTV
  49. 49. Multiplanar GTV and PTV
  50. 50. Smooth your contour
  51. 51. OAR DELINEATION OAR delineation
  52. 52. • VMAT • DCARC • 3DCRT • IMRT Planning
  53. 53. Beam arrangement
  54. 54. SL NO PARAMETER VALUE 1 D MAX 31.49Gy 2 D95% 27.38Gy 3 D100% 24.61Gy 4 V95% 100% 5 V25 Gy[V100%] 99.96% 6 V110% 94.20% 7 V120% 19.28 8 V130% 0 1. Prescription Isodose level is usually not 100% PD covering 100% PTV 2. Often 95% PD covering 95% PTV or higher 3. Or 100% PD covering 95% PTV or higher. Michael Torrens,/J Neurosurg (Suppl 2)/2014 PTV coverage index
  55. 55. • FORMULA • VOLUME OF PRESCRIPTION ISODOSE/PTV VOLUME • 4.956/4.161=1.19 • DESIRABLE=1 [Sonja Petkovska Proceedings of the Second Conference on Medical Physics and Biomedical Engineering] RTOG conformity index
  56. 56. • FORMULA (VOLUME OF PRESCRIPTION ISODOSE IN AREA OF INTEREST)2 PTV VOLUME X VOLUME OF PRESCRIPTION ISODOSE • 4.474x4.474/4.161X4.956=0.97 • IDEAL= > 0.85. AND <1 Michael Torrens,/J Neurosurg (Suppl 2)/2014 Paddick conformity index
  57. 57. • FORMULA • MAXIMUM DOSE/PRESCRIPTION DOSE • 31.49Gy/25Gy=1.25 • DESIRABLE = 1.1-1.3 HOMOGENITY index
  58. 58. • Dose fall off observation is very much needed in this evaluation under headings • Gradient index • Difference between various isodose lines • e.g between 80% and 60%- ideal- <2mm • Between 80% and 40%- ideal- < 8mm • For that reason we have to calculate equivalent radius Dose fall off
  59. 59. • To evaluate dose gradient we have to find out difference between radius of various isodose line • But none is iso spherical • We have to find out equivalent radius from formula • First find out the specified isodose volume • Then calculate the radius • V=4/3 πr3 • r= (3V/4π)1/3 Equivalent radius
  60. 60. SL NO PARAMETER VOLUME RADIUS 1 100% ISODOSE 4.956 1.06 2 80% ISODOSE 8.646 1.27 3 60% ISODOSE 13.761 1.49 4 50% ISODOSE 17.804 1.62 5 40% ISODOSE 24.334 1.8 r= (3V/4π)1/3 Equivalent radius
  61. 61. • FORMULA – Difference of equivalent radius of prescription isodose and equivalent radius of 50% isodose • 1.62mm-1.06mm=0.56mm • It should be between 0.3 to 0.9 Gradient index
  62. 62. • BETWEEN 80% AND 60%- IDEAL-<2mm • HERE1.49--1.27= 0.21mm • BETWEEN 80% AND 40%- IDEAL- <8mm – HERE1.8--1.27= 0.53mm EORTC-22952-26001 Distance between various isodose lines
  63. 63. CONSTRAINTS
  64. 64. SL NO ORGAN DESIRABLE ACHIEVED 1 RT. EYE MAX <22.5Gy 1Gy 2 LT. EYE MAX <22.5Gy 1.5Gy 3 RT. OPTIC NERVE MAX <22.5Gy 19.28Gy 4 LT. OPTIC NERVE MAX <22.5Gy 16Gy 5 OPTIC CHIASM MAX <22.5Gy 16.81Gy 8 BRAIN STEM MAX 23-31Gy 9 PIT STALK MEAN 24Gy 10 LT. cavernous sinus MEAN 21.26Gy 11 RT. cavernous sinus MEAN 24.35Gy GG HANNA/CLINICAL ONCOLOGY/2016 OAR coverage
  65. 65. DVH STAT TABLE
  66. 66. • MECHANICAL ISOCENTER CHECK – WINSTON LUTZ TEST • POINT DOSE VERIFICATION • TOLERANCE-1MM Travis R. Denton/JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS/2015 QA part
  67. 67. Dry run
  68. 68. • CBCT CORRECTIONS Set-up verification
  69. 69. • HEXAPOD CORRECTIONS Set-up verification
  70. 70. PREMEDICATION • TAB. DEXAMETHASONE 8MG THRICE DAILY STARTING DAY BEFORE • TAB. ONDANSETRON 8MG THRICE DAILY STARTING DAY BEFORE • TAB. PAN 4O ONCE DAILY STARTING DAY BEFORE • DIABETES CARE IF Pre medication-optional
  71. 71. • TAPER THE STEROID OVER A WEEK • ANTI EMETICS • PPI Post medication-optional
  72. 72. • Imaging after 6 months Advised
  73. 73. LETS UNDERSTAND ANATOMY
  74. 74. 2/26/2021 74
  75. 75. CAVERNOUS SINUS CAROTID ARTERY OPTI C CHIASMA INFUNDIBULUM PITUITARY 2/26/2021 75
  76. 76. INFUNDIBULAR RECESS SUPRA OPTIC RECESS OPTI C CHIASMA INFUNDIBULUM PITUITARY 2/26/2021 76
  77. 77. 2/26/2021 77
  78. 78. THE DISTANCE 2/26/2021 78
  79. 79. 2/26/2021 79
  80. 80. 2/26/2021 80
  81. 81. NORMAL PITUITARY- MRI PICTURES The adenohypophysis is isointense & the neurohypophysis is hyperintense- T1 PLANE Sagittal postcontrast T1shows normal diffuse enhancement of the gland 2/26/2021 81
  82. 82. PITUITARY MICROADENOMA- MRI PICTURES LEFT PART PITUITARY GLAND. WITHIN THE GLAND, A FOCAL AREA OF HYPOINTENSITY IS SEEN IN T1 PLANE Microadenoma remains hypointense while the remainder of the gland enhances IN T1 CONT 2/26/2021 82
  83. 83. DELAYED IMAGE 2/26/2021 83 1. Imaging more than 30 minutes after intravenous contrast also may help detect Microadenomas, which then appear as focal hyperintense lesions relative to the surrounding gland. 2. Encasement of the intercavernous internal carotid artery by adenoma greater than or equal to 67% was concluded to be a specific sign of a cavernous sinus invasion in one study. 3. Fat packed in the surgical defect appears hyperintense on T1- weighted sequences and requires the use of fat-saturated sequences to distinguish contrast enhancement from packing material
  84. 84. PITUITARY MACROADENOMA- MRI PICTURES There is a well defined round lesion noted in the pituitary fossa, the lesion is homogeneous and isodense on T1 There is a well defined homogeneously enhancing lesion in the pituitary fossa on Sagittal T1 C+ suggestive of pituitary adenoma 2/26/2021 84
  85. 85. CONVEX UPPER MARGIN IN PUBERTY 2/26/2021 85
  86. 86. 2/26/2021 86
  87. 87. RIGHT CAVERNOUS SINUS INVOLVEMENT 2/26/2021 87
  88. 88. HARDY’S CLASSIFICATION 2/26/2021 88
  89. 89. KNOSP CLASSIFICATION 2/26/2021 89
  90. 90. CAVERNOUS SINUS INVOLVEMENT 2/26/2021 90
  91. 91. DOCTORS • DR P S BHATTACHARYA • DR C R KUNDU • DR V K REDDY • DR SAJAL KAKKAR PHYSICISTS • MR A C PRABU • MR A SRINU • MR PRASAD • DR ANIL KUMAR TECHNOLOGIST TEAM Acknowledgments
  92. 92. FOLLOW UP • 3 MONTHLY FIRST 2 YEARS THEN 6 MONTHLY • HORMONAL CHECK UP FOR NORMALIZATION • HORMONAL CHECK UP FOR INSUFFICIENCY • OPHTHALMIC EVALUATION FOR RECOVERY • OPHTHALMIC EVALUATION FOR NEURITIS 2/26/2021 92
  93. 93. FOLLOW UP IMAGING • BASELINE EVALUATION AT 3 MONTH OF POST RADIATION • MRI PREFERRED • FURTHER IMAGING AT SYMPTOMATIC PROGRESSION 2/26/2021 93
  94. 94. VISUAL COMPLICATION 2/26/2021 94
  95. 95. OPTIC NEUROPATHY • Usual radiotherapy doses are 45 to 50Gy range. • This dose is below the tolerance of optic pathway including optic chiasm. • It allows for the treatment of pituitary adenomas of all sizes, including large tumors with suprasellar extension frequently encasing or in close proximity to the optic apparatus. • The toxicity of fractionated external beam RT is low, with a 1.5% risk of radiation-induced optic neuropathy • 0.2% risk of necrosis of normal brain structures 2/26/2021 95
  96. 96. PITUITARY INSUFFICIENCY  The most frequent late morbidity of radiation is hypopituitarism likely to be primarily the result of hypothalamic injury, although direct effect on the pituitary gland cannot be excluded.  In patients who have normal pituitary function around the time of RT, hormone replacement therapy is required in 20% to 40% at 10 years 2/26/2021 96
  97. 97. A. The 10-year PFS reported in seven large series of conventional external beam RT for pituitary adenoma is 80% to 94% . B. In the largest series of 411 patients, the 10- year PFS was 94% at 10 years and 89% at 20 years 2/26/2021 97
  98. 98. CONTROL AFTER STEREOTAXY Patients with GH–producing pituitary adenomas should not undergo further radiation therapy or surgery for at least 5 years after radiosurgery because GH and IGF-I levels continue to normalize over that interval 2/26/2021 98
  99. 99. RADIOSURGERY OUTCOMES 2/26/2021 99
  100. 100. PROLACTINOMA IS MORE RADIO-RESISTANCE 2/26/2021 100
  101. 101. TUMOR CONTROL 2/26/2021 101
  102. 102. DISEASE CONTROL 2/26/2021 102
  103. 103. LITERATURE REVIEW 2/26/2021 103
  104. 104. PATIENT COUNSELING 2/26/2021 104

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