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ORIGINAL RESEARCH article

Front. Oncol.
Sec. Radiation Oncology
Volume 15 - 2025 | doi: 10.3389/fonc.2025.1519445

Fractionated Robotic Radiosurgery for Unfavorable Nonfunctioning Pituitary Macroadenoma: 5-year Outcomes from a Single Institution Protocol

Provisionally accepted
Akrita Bhatnagar Akrita Bhatnagar 1*Monica Pernia Marin Monica Pernia Marin 2*Jonathan W Lischalk Jonathan W Lischalk 3*Min Ji Koh Min Ji Koh 1*Siviero Agazzi Siviero Agazzi 4*Simeng Suy Simeng Suy 1*Brent Harris Brent Harris 5,6*SUSMEETA TEWARI SHARMA SUSMEETA TEWARI SHARMA 7Edward Aulisi Edward Aulisi 7*Amjad Anaizi Amjad Anaizi 8*Mohamed H. Khattab Mohamed H. Khattab 9*Sean P Collins Sean P Collins 9*Brian T Collins Brian T Collins 9*Walter C Jean Walter C Jean 10,4*
  • 1 Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, District of Columbia, United States
  • 2 Department of Neuro-Oncology, Columbia University Irving Medical Center, Columbia University, New York, New York, United States
  • 3 Department of Radiation Oncology, Perlmutter Cancer Center, Langone Medical Center, New York University, New York, New York, United States
  • 4 Department of Neurosurgery and Brain Repair, Morsani College of Medicine, USF Health, Tampa, Florida, United States
  • 5 Department of Pathology, MedStar Georgetown University Hospital, Washington, DC, United States
  • 6 Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, United States
  • 7 Department of Endocrinology, MedStar Washington Hospital Center, Washington D.C., District of Columbia, United States
  • 8 Department of Neurosurgery, MedStar Georgetown University Hospital, Washington D.C., District of Columbia, United States
  • 9 Department of Radiation Oncology, University of South Florida, Tampa, Florida, United States
  • 10 Division of Neurosurgery, Lehigh Valley Fleming Neuroscience Institute, Pennsylvania, United States

The final, formatted version of the article will be published soon.

    OBJECTIVE: Nonfunctioning macroadenoma is a commonly diagnosed pituitary tumor. Resection is the favored treatment, with radiosurgery often utilized for residual or progressing disease. Long-term outcomes are established in the literature for single fraction frame-based radiosurgery, but mature outcomes are lacking for fractionated frameless radiosurgery. We report our institution’s 5-year efficacy and toxicity results for unfavorable nonfunctioning pituitary macroadenoma patients treated with 5-fraction robotic radiosurgery. METHODS: Between 2010-2020, patients who completed 5-fraction robotic radiosurgery for the treatment of unfavorable nonfunctioning pituitary macroadenomas were included. A tumor was considered unfavorable if the gross tumor volume (GTV) was larger than 5 cc or if it closely approached a critical structure (optic apparatus, brainstem, or pituitary gland). Local control was calculated using the Kaplan-Meier Method. RESULTS: Twenty predominately female patients (60%), ages 21-77 (median: 53 years), were included in this study. All underwent primary resection at the time of diagnosis. The indication for radiosurgery was tumor progression (n=14, 70%) or residual tumor after subtotal resection (n=6, 30%). Eighty-five percent of patients treated with radiosurgery (n=17) had cavernous sinus involvement. Median GTV was 3.4 cm3 (range: 0.3-20.8 cm3), and 40% of the tumors had suprasellar extension. A mean dose of 28.8 Gy (range: 25Gy-30Gy) was delivered to a median isodose line of 80% (range: 75%-89%). The median optic chiasm maximum point dose was 21.8 Gy (range: 12.0-25.0 Gy). Acute toxicity was minimal with 8 patients (40%) developing short-lived headaches and one patient (5%) developing a brief ipsilateral 6th nerve palsy. There was no late radiation-induced neurologic or optic dysfunction identified in this cohort. At a median follow-up of 5 years local control was 94%. There was 1 in-field failure pathologically confirmed following surgery for pituitary hemorrhage and 2 radiographically confirmed out-of-field failures in patients with larger tumors (>20 cc). CONCLUSIONS: The treatment of unfavorable nonfunctioning pituitary macroadenoma with 5-fraction robotic radiosurgery provides excellent local control to date, with acceptable toxicity. However, tumors with GTV’s greater than 20 cc may still require conventionally fractionated treatment with a margin to optimize local control.

    Keywords: Radiosurgery, Fractionated stereotactic radiosurgery, Nonfunctioning pituitary adenoma, local control, CyberKnife

    Received: 29 Oct 2024; Accepted: 07 Jan 2025.

    Copyright: © 2025 Bhatnagar, Marin, Lischalk, Koh, Agazzi, Suy, Harris, SHARMA, Aulisi, Anaizi, Khattab, Collins, Collins and Jean. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

    * Correspondence:
    Akrita Bhatnagar, Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, 20007, District of Columbia, United States
    Monica Pernia Marin, Department of Neuro-Oncology, Columbia University Irving Medical Center, Columbia University, New York, NY 10027, New York, United States
    Jonathan W Lischalk, Department of Radiation Oncology, Perlmutter Cancer Center, Langone Medical Center, New York University, New York, 10016, New York, United States
    Min Ji Koh, Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, 20007, District of Columbia, United States
    Siviero Agazzi, Department of Neurosurgery and Brain Repair, Morsani College of Medicine, USF Health, Tampa, 33606, Florida, United States
    Simeng Suy, Department of Radiation Medicine, MedStar Georgetown University Hospital, Washington, DC, 20007, District of Columbia, United States
    Brent Harris, Department of Pathology, MedStar Georgetown University Hospital, Washington, DC, United States
    Edward Aulisi, Department of Endocrinology, MedStar Washington Hospital Center, Washington D.C., District of Columbia, United States
    Amjad Anaizi, Department of Neurosurgery, MedStar Georgetown University Hospital, Washington D.C., 20007, District of Columbia, United States
    Mohamed H. Khattab, Department of Radiation Oncology, University of South Florida, Tampa, 33620, Florida, United States
    Sean P Collins, Department of Radiation Oncology, University of South Florida, Tampa, 33620, Florida, United States
    Brian T Collins, Department of Radiation Oncology, University of South Florida, Tampa, 33620, Florida, United States
    Walter C Jean, Department of Neurosurgery and Brain Repair, Morsani College of Medicine, USF Health, Tampa, 33606, Florida, United States

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