Chief Cushie ~MaryO~ Posted October 22, 2021 Chief Cushie Report Share Posted October 22, 2021 MeganOrrMD, JamesFindlingMD, NathanZwagermanMD, JenniferConnellyMD, KatherineAlbanoMS, JosephBoviMD Show more https://doi.org/10.1016/j.adro.2021.100813Get rights and content Under a Creative Commons license open access Abstract Pituitary carcinoma (PC) is an uncommon intracranial malignancy with a high rate of metastasis, mortality, and inconsistent response to therapy. Because PC is a rare condition (0.1%-0.2% of pituitary tumors), prospective studies and observable data are scarce. Some PC may have an endocrine secretory function and can arise from existing pituitary adenomas. Treatment often includes a combination of surgical resection, radiotherapy, and systemic therapies. Because of the poor treatment response rate and rapid progression, treatment is often palliative. Here we describe a unique, complete amelioration of severe Cushing's disease due to an ACTH secreting pituitary carcinoma followed by the development of pituitary hypoadrenalism after re-irradiation with concurrent temozolomide. Summary Pituitary carcinoma is a rare malignancy with high rates of metastases at diagnosis, inconsistent therapeutic response, and high mortality. Treatment includes a combination of surgical resections, radiotherapy, and medications. Because of the poor treatment response rate and rapid progression, treatment is often palliative. This report describes the complete resolution of severe Cushing's disease due to an ACTH secreting pituitary carcinoma followed by the development of pituitary hypoadrenalism after re-irradiation and concurrent temozolomide radio-sensitization. Introduction Pituitary adenomas (PA) are a common, benign tumor managed with combinations of surgery, radiotherapy, and medication. While uncommon, there are atypical PA with aggressive behaviors that are refractory to treatment. In rare instances, pituitary tumors can metastasize or spread. These malignant behaving tumors are called pituitary carcinomas (PC). PC is challenging to manage as they metastasize early and have a poor response to treatment. In reported PC cases, malignant transformation of atypical adrenocorticotrophic hormone (ACTH) secreting PA is a common pathogenesis.1 Features of PC include functional ACTH production and resistance to radiation. Because of the aggressive nature and systemic spread, the prognosis is poor with a high mortality rate of 66% at one year.2 Prospective studies and observable data are scarce. Prior reports of treatment include a combination of surgical resection, radiotherapy, and medication with inconsistent responses. Because of the poor treatment response rate and rapid progression, treatment is often palliative. This report describes a complete resolution of severe Cushing disease due to an ACTH secreting pituitary carcinoma followed by the development of pituitary hypoadrenalism after re-irradiation with concurrent temozolomide. Case Description A 53-year female presented with complaints of blurry vision, right-sided cranial nerve (CN) III palsy, diffuse edema of her face and extremities, and a 15 lb. weight gain over 2 weeks. Visual field testing revealed bitemporal hemianopsia which prompted imaging. MRI demonstrated a large intracranial sellar mass (4.0 × 4.3 cm) invading the suprasellar cistern and compressing the optic chiasm. ACTH and cortisol were elevated, which combined with radiographic evidence, established a diagnosis of an ACTH-secreting pituitary macroadenoma and Cushing's disease (CD). The patient underwent a transsphenoidal tumor debulking, followed by CyberKnife stereotactic radiosurgery two months after surgery (treated to 24 Gy, seeTable 2). Pathology revealed an atypical PA, positive for p53 and with a low Ki-67 index. Table 1. Clinical Course Date Condition 24 h urinary cortisol* Late salivary cortisol* Serum morning cortisol* ACTH* Nov 2009 Before 1st debulking surgery 3,192 N/A N/A 635 Feb 2010 Cyberknife 6.9 1.5 9.6 134 May 2014 Redo-Debulking 40.2 5.5 11.8 190.0 August 2017 3 months post RT 20.1 5.5 39.4 240.8 May 2018 1 year post RT 16.0 5.9 12.6 199.8 Feb 2019 1 year and 6 months post RT 2.1 3.6 6.8 111.8 Jan 2020 Post 3rd Debulking N/A N/A 8.4 88.5 ⁎ 24h urinary cortisol (NR:30-310 ug/24h). Late salivary cortisol(NR < 0.13 ug/dL). Serum morning cortisol (NR: 5-25 ug/dL). ACTH (NR <46 pg/dL) GC: glucocorticoids, CS: Cushing syndrome Table 2. CyberKnife Radiation Treatment Plan Cyber Knife Feb 2010 Target/OAR Volume(cm3) Max Dose(cGy) Min Dose(cGy) Mean Dose(cGy) Standard deviation (SD)(cGy) CTV 7 2817 1214 2403 240 PTV 6 2817 1323 2457 204 Brain Stem 34 1023 28 250 160 Left Eye 7 65 16 29 7 LON 2 1069 39 233 223 Optic Chiasm 1 845 194 448 164 Right Eye 7 164 16 31 12 RON 2 1267 48 298 216 After three years in remission, she experienced worsening symptoms associated with cortisol excess. Medical management of cabergoline (D2 receptor agonist) followed by pasireotide (somatostatin analog) was tried without clinical improvement. Imaging demonstrated the mass had recurred with non-congruent intracranial spread. This noncontiguous intracranial growth met the criteria for PC. A second transsphenoidal subtotal resection was performed. Pathology revealed atypical ACTH secreting adenoma with a similarly low Ki-67, but with a new loss of p53 signaling. Despite debulking, she had biochemical persistence of hypercortisolism. Over the next two months, the patient declined rapidly with weakness, and worsening Cushing's symptoms. She was enrolled in a Phase III clinical trial with osilodrostat (11-Beta hydroxylase inhibitor) however, could not tolerate the investigational drug and was taken off. Subsequent MRI showed evidence of progression with gross residual disease and interval growth. She was referred to radiation oncology. She completed a course of image-guided, intensity modulated, radiotherapy (IG-IMRT) with concurrent temodar (TMZ) radiosensitization. TMZ was dosed at 75 mg/m2 per day for 42 days during radiation. Her IG-IMRT plan consisted of a gross tumor volume (GTV); drawn for MR defined gross disease and a clinical target volume (CTV) encompassing gross disease at risk areas of microscopic disease extension (Figure 1). These volumes were then expanded to 2 planning target volumes (PTV). The first, and larger, PTV was created by expanding the CTV to PTV1 and treated to 50.4 Gy in 28 fractions (180 cGy/fraction). The GTV alone was expanded to PTV2 (integrated boost) and was treated to a total dose of 56 Gy in 28 fractions (200 cGy/fraction) (See Table 3). Over the next two years, the patient had a steady decline in ACTH and cortisol levels and experienced a significant improvement in CD symptoms. Amazingly, she developed hypocortisolemia. Following concurrent chemo-RT, her leg strength and ambulation improved, and she endorsed improvements in vision. Surveillance images taken a year and a half after chemo-RT showed stable size and configuration of the residual sella and parasellar lesion with obvious shrinkage of the residual PC compared to prior scans. Download : Download high-res image (798KB) Download : Download full-size image Figure 1. IG-IMRT Planning Images Radiotherapy Planning session MRI T1 weighted images with contrast (March 2017) showing PTV's and prescribed isodose lines. Red lines: 5600 cGy, dose1. Yellow lines: 5040 cGy, dose 2. Orange lines: PTV1. Purple lines: PTV2. Table 3. IG-IMRT Radiation Treatment Plan IG-IMRT May 2017 Target/OAR Volume(cm3) Max Dose(cGy) Min Dose(cGy) Mean Dose(cGy) SD(cGy) EqD2 (cGy) GTV 83 6091 4922 5621 233 CTV 24 6083 5292 5793 102 PTV 1 241 6118 4753 5423 270 PTV 2 51 6118 5074 5779 106 Brain Stem 32 5784 2374 4701 586 4324 CHIASM PRV 5 5640 4881 5266 171 5109 Eye_L 8 3173 537 1355 574 841 Eye_R 7 3680 542 1551 644 990 EyeLens_L 0.1 997 614 765 81 435 EyeLens_R 0.1 830 626 719 41 406 InnerEar_L 0.5 5088 4235 4687 164 4305 InnerEar_R 0.4 5673 4853 5165 112 5175 LacrimalGland_L 0.7 2207 734 1313 382 810 LacrimalGland_R 0.8 2518 1064 1736 340 1137 OpticChiasm 0.8 5367 4881 5177 89 4981 OpticNerve_L 0.5 5325 2742 4723 592 4353 OpticNerve_R 0.6 5327 3149 4799 493 4456 EqD2: Equivalent dose in 2 Gy fractions Two years following concurrent chemo-RT, a new clival nodule was noted on imaging. Biopsy confirmed pituitary carcinoma. This was managed with single fraction Gamma Knife delivering a margin dose of 16 Gy (Figure 2) to the biopsied area of recurrence. She remains in clinical remission with stable tumor appearance on recent imaging (Figure 3). Download : Download high-res image (686KB) Download : Download full-size image Figure 2. Gamma Knife Radiation Therapy Planning Images Gamma Knife Planning session MRI T1 weighted images with contrast (May 2020) showing GTV and prescribed isodose line. Red lines: 1600 cGy prescribed dose. Blue lines: GTV. Download : Download high-res image (469KB) Download : Download full-size image Figure 3. Follow-up Imaging Follow up MRI imaging (Jan 2021) showing stable tumor appearance at 8 months post-GK, and 46 months post-IGMRT with TMZ. Discussion Over a ten-year history of persistent symptoms and aggressive tumor behavior, this patient's diagnosis evolved from an atypical ACTH secreting pituitary macroadenoma to an invasive ACTH secreting pituitary carcinoma (PC) that was managed by fractionated imaged-guided intensity modulated radiotherapy (IG-IMRT) with concurrent temozolomide (TMZ). Approximately two years post-IG-IMRT, ACTH/cortisol labs had declined, and the lesion was reduced radiographically. Remarkably, she developed hypocortisolemia mandating hydrocortisone replacement therapy despite an elevated plasma ACTH. It is postulated that the remission of Cushing's disease was likely related to chemo-radiotherapy-induced alterations in the post-translation processing of proopiomelanocortin (POMC) with the production of biologically inactive ACTH and significant decreases in cortisol biosynthesis.4 To date, the patient endorses substantial strength, visual, and cognitive improvement. The mainstay of PC treatment begins with surgical transsphenoidal resection, followed by radiotherapy for residual tumor growth, and adjuvant medical treatment. Studies show in the case of atypical PA that progress to PC, early and aggressive treatment provides the longest survival.3 Surgical resection is the initial intervention to avoid morbidity and mortality related to mass effect of these large aggressive tumors, however, it is rarely complete.3 As a result, the residual disease progresses, and multiple surgeries may be performed after a recurrence of disease. Primary pituitary tumors that present with metastases at diagnosis are termed PC. If no metastases are present, histological evaluation can aid in the management of the tumor.3 Tumors with a high mitotic index, high Ki-67 index >3%, and/or p53 immunoreactivity are termed atypical PA for their aggressive growth and tendency to recur after resection.3 In both PC and atypical PA guidelines, evidence of post-surgical growth is treated with radiation therapy. In general, radiotherapy provides a modest benefit of local tumor control, especially when administered before distant metastases arise in atypical PA with malignant potential.3 Focal stereotactic treatment has shown mostly palliative benefit with little prognostic improvement.3 Finally, medical therapy is used to combat tumor growth and hypersecretory function. Non-chemotherapy biotherapy includes somatostatin analogs, particularly in the case of GH and TSH-producing tumors, with variable tumor reduction and a limited period of control. Chemotherapy agents such as doxorubicin, cisplatin, and etoposide-based chemotherapy have been implicated in the treatment of PC.3 Responses are variable and not widely replicated, but observational studies indicated prolonged survival in cases of distant metastases, and in aggressive atypical PA before malignant transformation.1-3 One report demonstrated significant regression of an ACTH-secreting PC and distant metastases induced with cisplatin and etoposide, two cytotoxic platinum-based chemotherapy drugs.4 These agents have variable CNS penetrance, unlike TMZ, but have potential benefit in cases of PC with high mitotic indices. Without prospective, randomized studies, significant conclusions on the benefits of chemotherapeutic agents have yet to be made. Current guidelines for PC that demonstrate progression after primary tumor debulking and radiotherapy include further surgery (alpha), focused radiotherapy (beta), chemotherapy (gamma), and treatment with radionuclides (delta).3 In this case, a complex PC/recurrent atypical PA had a stable positive response to combined fractionated IG-IMRT and TMZ, demonstrating radiological decrease in tumor volume, clinical improvement, and endocrine remission status post 1 year and 8 months. The lasting results of a combined therapy approach in treating PC have been illustrated in other literature examples. In a similar case, an ACTH secreting PC was treated with a course of concurrent radiotherapy, TMZ, and bevacizumab, an anti-VEGF monoclonal antibody.5 The multimodality course was implemented six weeks post-resection. At eight weeks, the resolution of a distant metastasis helped established a positive outcome. The patient followed up this course with a year of adjuvant TMZ. Five years post treatment, there has been no evidence of recurrent disease on imaging or with ACTH monitoring.5 Another report found that an aggressive, functional ACTH-producing pituitary adenoma was managed with concurrent TMZ and radiotherapy after failing maximal conventional therapy. As in the presented PC case, this PA was recurrent after surgical, medical, and radiotherapy interventions. It rapidly progressed biochemically, radiologically, and clinically. After initiating the combined concurrent TMZ and radiation, a rapid biochemical response was observed with cortisol normalization and regression of intracranial tumor volume on MRI at 3 and 6 months. The TMZ therapy was stopped after the sixth cycle, and at twenty-two months out from treatment, the patient continues to have stable tumor volume and biochemical remission. Although the patient did not have metastasis necessary for classification of PC, the recurrent clinical course and aggressive functional nature of the tumor demonstrate the lasting positive outcome of a combined modality approach on tumor growth and endocrine remission.6 In presenting this case, fractionated IG-IMRT with TMZ was effective in achieving stable endocrine remission and partial tumor regression for several years’ duration. The recurrent clival PA is ACTH non-secreting after IG-IMRT and concurrent TMZ which has improved the patient's clinical condition. Although this mass recurred after treatment, it is quite remarkable that her tumor has remained hormonally nonfunctional, and the patient continues to have a resolution of CD symptoms. Limited clinical information exists on successful treatment options for PC. Recurrence, metastasis, and mortality are high after exhausting conventional treatment. The alternative combined therapeutic approach of current TMZ and radiation has shown rare, and lasting effects in this patient. These findings may further support the use of combined fractionated radiotherapy with concurrent TMZ treating in patients with ACTH-secreting PC who fail standard surgical and medical interventions. References 1 Joehlin-Price, A. S., Hardesty, D. A., Arnold, C. A., Kirschner, L. S., Prevedello, D. M., & Lehman, N. L. (2017). Case report: ACTH-secreting pituitary carcinoma metastatic to the liver in a patient with a history of atypical pituitary adenoma and Cushing's disease. Diagnostic Pathology, 12(1), 1–8. https://doi.org/10.1186/s13000-017-0624-5 2 Borba, C. G., Batista, R. L., Musolino, N. R. de C., Machado, V. C., Alcantara, A. E. E., Silva, G. O. da, … Cunha Neto, M. B. C. da. (2015). Progression of an Invasive ACTH Pituitary Macroadenoma with Cushing's Disease to Pituitary Carcinoma. Case Reports in Oncological Medicine, 2015(Cd), 1–4. https://doi.org/10.1155/2015/810367 3 Kaltsas, G. A., Nomikos, P., Kontogeorgos, G., Buchfelder, M., & Grossman, A. B. (2005). Clinical review: Diagnosis and management of pituitary carcinomas. Journal of Clinical Endocrinology and Metabolism, 90(5), 3089–3099. https://doi.org/10.1210/jc.2004-2231 4 Cornell, R.F., Kelly, D. F., Bordo, G., Corroll, T. B., Duong, H. T., Kim, J., Takasumi, Y., Thomas, J. P., Wong, Y. L., & Findling, J. W. (2013). Chemotherapy-Induced Regression of an Adrenocorticotropin-Secreting Pituitary Carcinoma Accompanied by Secondary Adrenal Insufficiency. Case Reports in Endocrinology, 2013;2013:675298 https://doi.org/10.1155/2013/675298 5 Touma, W., Hoostal, S., Peterson, R. A., Wiernik, A., SantaCruz, K. S., & Lou, E. (2017). Successful treatment of pituitary carcinoma with concurrent radiation, temozolomide, and bevacizumab after resection. Journal of Clinical Neuroscience, 41, 75–77. https://doi.org/10.1016/j.jocn.2017.02.052 6 Misir Krpan, A., Dusek, T., Rakusic, Z., Solak, M., Kraljevic, I., Bisof, V., … Kastelan, D. (2017). A Rapid Biochemical and Radiological Response to the Concomitant Therapy with Temozolomide and Radiotherapy in an Aggressive ACTH Pituitary Adenoma. Case Reports in Endocrinology, 2017, 1–5. https://doi.org/10.1155/2017/2419590 Funding: None Disclosures: Dr. Findling reports grants, personal fees and other from Novartis, personal fees and other from Corcept Therapeutics, personal fees from Recordati, outside the submitted work. Research data are stored in an institutional repository and will be shared upon request to the corresponding author. © 2021 The Authors. Published by Elsevier Inc. on behalf of American Society for Radiation Oncology. From https://www.sciencedirect.com/science/article/pii/S2452109421001718 1 Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You can post now and register later. If you have an account, sign in now to post with your account.