Sachio Nabeshima

The efficacy of conventional radiation therapy in the management of pituitary adenoma

PURPOSE To evaluate the efficacy of conventional radiotherapy for reducing tumor size and endocrine hypersecretion of pituitary adenomas. METHODS AND MATERIALS We reviewed the records of 91 patients with pituitary adenoma, who were first treated between 1969 and 1994 and had been followed for more than 2 years (median, 8.2 years.) Of these patients, 86 had received postoperative radiotherapy, and 5 had received radiotherapy alone. The median total dose was 51 Gy. Clinical symptoms related to mass effects or endocrine hypersecretion were assessed. The efficacy of radiotherapy was evaluated before treatment and during the follow-up period (1-14 years; median, 3 years) by estimating tumor size on computed tomography or magnetic resonance imaging in 56 patients, as well as by endocrine testing in the 22 patients who had secreting adenomas. Local control rate, prognostic factors, and side effects were analyzed. RESULTS Mass-effect symptoms improved in 72% and 79% of patients who had such symptoms due to nonsecreting adenomas and secreting adenomas, respectively. Symptoms of endocrine hypersecretion abated in 67% of patients who had such symptoms. Excessive hormone levels normalized in 74% of patients who showed endocrine hypersecretions. The greatest size reduction was seen 3 years after the completion of radiotherapy (24% CR, 62% PR, 12% NC, and 3% PD in nonsecreting adenomas, and 32% CR, 36% PR, 27% NC, and 5% PD in secreting adenomas). Three patients with secreting adenomas (2 with prolactinoma and 1 with Cushings disease) showed a mismatch between reduction in tumor size and normalization of endocrine hypersecretion. The 10-year local control rates were 98%, 85%, 83%, and 67% for nonsecreting adenoma, growth-hormone-secreting adenoma, prolactinoma, and Cushings disease, respectively. Univariate analyses showed that disease type and radiation field size were significant prognostic factors. Brain necrosis occurred in 1 patient who received a 60-Gy dose of irradiation. CONCLUSION We conclude that conventional external radiotherapy with 50 Gy is safe and sufficient to control pituitary adenoma. Careful observation is required in the management of secreting adenomas because the effects on tumor size and endocrine hypersecretion may be mismatched in some secreting adenomas.

Intracranial double teratomas

A case of double teratomas located in the pineal region and the fourth ventricle is presented. A simultaneous occurrence from nonmetastatic, separate origins seems rare in cases of mature teratomas. Computerized tomographic scans led to detection of another asymptomatic teratoma. Surgical treatment produced good results.

Chemodectoma of the Glomus Jugulare with Multiple Metastases

A relatively rare case of chemodectoma of the glomus jugulare with multiple metastases is reported. Ten years ago, a 37-year-old male was seen because of dysphagia and a mass in the right retro-auricular region. The mass in the right jugular foramen was partially resected and irradiated. Histological examination revealed a chemodectoma. Five years thereafter the patient was readmitted with an epidural mass involving the left eighth cervical nerve root. One year later he developed a chest pain and lumbago. A bone scan revealed multiple skeletal metastases. Histologically, specimens from the right parietal bone and the right 10th rib showed a chemodectoma. He was again irradiated. He was again admitted with paraplegia, 9 years after the first admission. With repeated irradiation with a total dose of 16, 700 rads in 10 years, he died with cachexia and aspiration pneumonia at the age of 47. The autopsy revealed multiple metastases of chemodectoma to bone, spinal epidural space, lung, and pancreas. Although chemodectoma of the glomus jugulare is generally considered to be a rare benign tumor, slow metastatic spread to various organs is not uncommon. A careful search for metastatic lesions, possibly for years is essential when following up the patient.

Spontaneous Extrusion of Peritoneal Tubes after Ventriculoperitoneal Shunting

Migration of peritoneal tubes was observed in two cases of ventriculoperitoneal (VP) shunting. The first patient had undergone revision of VP shunting for hydrocephalus at the age of 7 months. He had been well until the age of 16 months, when umbilical erosion was noted. Physical examination revealed that the distal tip of the peritoneal tube (non-spiral wire type) was protruding through the umbilicus. However, the patient was well, and the tube was replaced. The removed tube was contaminated with Staphylococcus aureus, but administration of antibiotics prevented postoperative infection. The second patient, an 8-month-old boy, was brought in because of failure to thrive and feeding difficulty 5 months after VP shunting for hydrocephalus. Physical examination disclosed that the distal tip of the peritoneal tube (again, a non-spiral wire type) was protruding through the anus. The cerebrospinal fluid obtained by puncture of the fontanelle yielded a turbid fluid. There was no evidence of peritonitis. The distal tube was removed, and ventricular drainage, along with administration of antibiotics, was maintained for 1 month. The shunting system was then revised. There have been 53 reported cases of migration of shunting tubes, most of which were located in the bowel. Transumbilical migration has been previously reported only once. In that case as well as ours, Pudenz peritoneal tubes without a spiral wire were used. However, several authors have noted an increased incidence of spontaneous extrusion of the Raimondi type peritoneal tube with a spiral wire. Meningitis and/or ventriculitis carried the worst prognosis. Patients with VP shunts should be regularly examined to avoid the sort of rare complication described here.