[please see previous post to see the clinical details of this discussion.
From: Arvind Bhateja To: neurosurgery nimhansATyahoogroup
Sent: Monday, December 22, 2008 11:48:42 AM
Subject: Re: Question of the week. Gh secreting residual.
Hi GKand Happy new year everyone!
In my opinion, the best option would be to re-operate this gentleman via an endoscopic trans-sphenoidal which should be able to decompress tumor around the carotid and cav sinuses.
To tackle the bleeding one would probably need to have thrombin solution or floseal.
Its probably the best way although many would find this option more painful.
If endoscopic is an issue an orbitozygomatic with an interdural approach to the cav sinus might also do the job, but it would be overkill for such a small residual.
Almost surely he is going to require hormonal control with cabergoline post-operatively, which might also aid tumor regression if there is still a small residual.
Thanks GK for posing us these teasers and looking forward to some interesting responses!
Arvind
Dr Arvind Bhateja
Consultant Neurosurgeon and Spine Surgeon,
Sita Bhateja Speciality Hospital
Bangalore 560025, INDIA
From: Dr Pramod Pillai To: neurosurgerynimhans
Sent: Tuesday, December 23, 2008 7:04:55 PM
Subject: Re: Question of the week. Gh secreting residual.
Dear All
Merry Xmas and happy new year!!!
I would still try to get his preop and follow up images, see how this tumor behaved over the last 1 year.
If this is just a residual tumor with no significant growth over the last one year, tumor control wont be my concern, instead I would try to treat him
medically with a combination of GH receptor antagonist , pegvisomant with Sandostatin or Somatuline.then follow him with serial images and GH/IGF levels.Patient' s affordability could be an issue
Otherwise , I would rather offer him radiosurgery of his parasellar tumor, it looks like there is enough space between the optic pathway the superior margin of the tumor( we need atleast 2mm distance) , but unlike the nonfunctioning tumors, functioning tumors need higher radiation dose , but there are several methods by which we can reduce dose to the optic pathway to below 8Gy.Nevertheless, there is risk to radiation injury to the cranial nerves in cavernous sinus region, but risk is definitely less than with any surgical approach .Another issue with radiosurgery is latency period , for therapeutic response, during which patient need to be on medical therapyagain. There could be small bit of tumor on the left parasellar region as well?
I wont recommend surgery for this patient , no single approach or surgery is going to cure him off his disease without cranial nerve morbidity, I am also concerned that tumor was encircling the cavernous carotid.
Pramod
From: gopalakrishnan ms
To: neurosurgery_ nimhans
Sent: Tuesday, December 23, 2008 11:53:59 AM
Subject: Re: [neurosurgery_ nimhans] Question of the week. Gh secreting residual.
Please note: The current MRI was done recently [within three months]. Preoperative GH levels were around 40 at the time of primary surgery one year back. An immediate post op MRI was not done. So this is basically a hormonally active residue. He can afford either surgery or radiosurgery (if offered at concessional rate as is done in NIMHANS) but not expensive drugs for an indefinite period.
Shall i take the liberty of adding a sub-question? :
1. What if there is no visible tumor remnant, yet the GH level is high? Is radiosurgical targetting of the entire sella an option?
Wish you Merry Christmas!
GK
From: Dr Pramod Pillai To: neurosurgery_ nimhans@yahoogro
In that case , I would go ahead with radiosurgery, hoping that it provides a hormonal remission so that he can be off the medication later on
The reported remission rate with radiosurgery is about 30-70 %.You do not have to include sella in the target in this case since there is hardly any tumor in the sella.It looks like previous surgeon had tried to preserve the normal pituitary with an intact pituitary stalk( how is his other endocrine functions?)
In rare situations, with all failed therapies with no radiological evidence of tumor in pituitary gland and if you are unable to find another source esp with Cushing's disease, sometimes pituitary gland can be targeted for radisurgery.
If you still like to do surgery on him, carefully study his vascular anatomy.With limited images you provided, I still feel there is encircling of ICA by the tumor , even there is reduced caliber of ICA on the right side. I still feel it is less likely that we can surgically cure him of the disease without causing any additional morbidity.
--- On Thu, 12/25/08,
From: brmrao1963
Subject: [neurosurgery_ nimhans] Re: Question of the week. Gh secreting residual.
To: neurosurgery_ nimhans@yahoogro ups.com
Date: Thursday, December 25, 2008, 6:14 PM
Wishing All of You a very happy and prosperous new year!
I am joining the discussion late. The patient in question has a residual secreting growth
hormone adenoma in the paracavernous area ,probably in the cavernous sinus.
Now the ideal treatment of a GH adenoma residual would be surgery-
1.endoscopic approach
2.miniorbitozygomat ic approach (interdural) .
The drawback of endoscopic approach is this tumor will require an extended endoscopic
approach .This require the surgeon to be extremely conversant with the approach-not
practical for many of us,though I personally do endoscpic pituitary surgery.
This tumor can be removed by an frontotemporal interdural approach which can be
conducted with minimal morbidity. The cranial nerves III and IV can be traced intradurally and interdurally to spare them from injury. I can speak with confidence regarding this approach as I am very familiar with the nuances of this approach.
This tumor cannot be treated with radiotherapy- period!
GKS is an option but may fail. ICA stenosis is a well known complication of GKS. With in adequate contouring cranial nerve palsies are possible!
So the 2 options are interdural approach Vs GKS. My vote is for interdural approach and this will not be overkill as high GH can kill!;patient cannot afford long-term drugs and GKS may or may-not succeed!
Cheers!
Ravi Mohan Rao
Hi all, I agree with Dr. ravi mohan Rao. this can be approached with either extended endoscopic approach or orbitozygomatic. OZ approach is really not morbid procedure as we have done for cavernous sinus tumors. I feel its morbid for the surgeon if u dont have themicro saw drill. not morbid for patient.
GK thanks for posting such cases
regards
Dr.Praveen Ganigi
Consultant Neurosurgeon & Spinal Surgeon
Narayana Institute Of Neurosciences,
Bangalore- 560099
Further update on this patient [Nov '09]
Thank you for all your suggestions...
I had taken a decision to send the patient for gammaknife radiosurgery. [Radiosurgery is not available in jipmer as of now] However, there were some apprehension of cranial nerve deficits, especially optic nerve injury - and the quantum of risks that was explained to the patient was unacceptable to him.
He underwent stereotactic radiotherapy at CMC vellore two months back. He is under follow up. Symptoms persists.
Personally I feel he will eventually require radiosurgery at a future date when the risks of cranial nerve morbidity will be even higher due to previous irradiation. (or microneurosurgery) Ill update you on his response ... though that will be many years away.
From: Arvind Bhateja To: neurosurgery nimhansATyahoogroup
Sent: Monday, December 22, 2008 11:48:42 AM
Subject: Re: Question of the week. Gh secreting residual.
Hi GKand Happy new year everyone!
In my opinion, the best option would be to re-operate this gentleman via an endoscopic trans-sphenoidal which should be able to decompress tumor around the carotid and cav sinuses.
To tackle the bleeding one would probably need to have thrombin solution or floseal.
Its probably the best way although many would find this option more painful.
If endoscopic is an issue an orbitozygomatic with an interdural approach to the cav sinus might also do the job, but it would be overkill for such a small residual.
Almost surely he is going to require hormonal control with cabergoline post-operatively, which might also aid tumor regression if there is still a small residual.
Thanks GK for posing us these teasers and looking forward to some interesting responses!
Arvind
Dr Arvind Bhateja
Consultant Neurosurgeon and Spine Surgeon,
Sita Bhateja Speciality Hospital
Bangalore 560025, INDIA
From: Dr Pramod Pillai To: neurosurgerynimhans
Sent: Tuesday, December 23, 2008 7:04:55 PM
Subject: Re: Question of the week. Gh secreting residual.
Dear All
Merry Xmas and happy new year!!!
I would still try to get his preop and follow up images, see how this tumor behaved over the last 1 year.
If this is just a residual tumor with no significant growth over the last one year, tumor control wont be my concern, instead I would try to treat him
medically with a combination of GH receptor antagonist , pegvisomant with Sandostatin or Somatuline.then follow him with serial images and GH/IGF levels.Patient' s affordability could be an issue
Otherwise , I would rather offer him radiosurgery of his parasellar tumor, it looks like there is enough space between the optic pathway the superior margin of the tumor( we need atleast 2mm distance) , but unlike the nonfunctioning tumors, functioning tumors need higher radiation dose , but there are several methods by which we can reduce dose to the optic pathway to below 8Gy.Nevertheless, there is risk to radiation injury to the cranial nerves in cavernous sinus region, but risk is definitely less than with any surgical approach .Another issue with radiosurgery is latency period , for therapeutic response, during which patient need to be on medical therapyagain. There could be small bit of tumor on the left parasellar region as well?
I wont recommend surgery for this patient , no single approach or surgery is going to cure him off his disease without cranial nerve morbidity, I am also concerned that tumor was encircling the cavernous carotid.
Pramod
From: gopalakrishnan ms
To: neurosurgery_ nimhans
Sent: Tuesday, December 23, 2008 11:53:59 AM
Subject: Re: [neurosurgery_ nimhans] Question of the week. Gh secreting residual.
Please note: The current MRI was done recently [within three months]. Preoperative GH levels were around 40 at the time of primary surgery one year back. An immediate post op MRI was not done. So this is basically a hormonally active residue. He can afford either surgery or radiosurgery (if offered at concessional rate as is done in NIMHANS) but not expensive drugs for an indefinite period.
Shall i take the liberty of adding a sub-question? :
1. What if there is no visible tumor remnant, yet the GH level is high? Is radiosurgical targetting of the entire sella an option?
Wish you Merry Christmas!
GK
From: Dr Pramod Pillai To: neurosurgery_ nimhans@yahoogro
In that case , I would go ahead with radiosurgery, hoping that it provides a hormonal remission so that he can be off the medication later on
The reported remission rate with radiosurgery is about 30-70 %.You do not have to include sella in the target in this case since there is hardly any tumor in the sella.It looks like previous surgeon had tried to preserve the normal pituitary with an intact pituitary stalk( how is his other endocrine functions?)
In rare situations, with all failed therapies with no radiological evidence of tumor in pituitary gland and if you are unable to find another source esp with Cushing's disease, sometimes pituitary gland can be targeted for radisurgery.
If you still like to do surgery on him, carefully study his vascular anatomy.With limited images you provided, I still feel there is encircling of ICA by the tumor , even there is reduced caliber of ICA on the right side. I still feel it is less likely that we can surgically cure him of the disease without causing any additional morbidity.
--- On Thu, 12/25/08,
From: brmrao1963
Subject: [neurosurgery_ nimhans] Re: Question of the week. Gh secreting residual.
To: neurosurgery_ nimhans@yahoogro ups.com
Date: Thursday, December 25, 2008, 6:14 PM
Wishing All of You a very happy and prosperous new year!
I am joining the discussion late. The patient in question has a residual secreting growth
hormone adenoma in the paracavernous area ,probably in the cavernous sinus.
Now the ideal treatment of a GH adenoma residual would be surgery-
1.endoscopic approach
2.miniorbitozygomat ic approach (interdural) .
The drawback of endoscopic approach is this tumor will require an extended endoscopic
approach .This require the surgeon to be extremely conversant with the approach-not
practical for many of us,though I personally do endoscpic pituitary surgery.
This tumor can be removed by an frontotemporal interdural approach which can be
conducted with minimal morbidity. The cranial nerves III and IV can be traced intradurally and interdurally to spare them from injury. I can speak with confidence regarding this approach as I am very familiar with the nuances of this approach.
This tumor cannot be treated with radiotherapy- period!
GKS is an option but may fail. ICA stenosis is a well known complication of GKS. With in adequate contouring cranial nerve palsies are possible!
So the 2 options are interdural approach Vs GKS. My vote is for interdural approach and this will not be overkill as high GH can kill!;patient cannot afford long-term drugs and GKS may or may-not succeed!
Cheers!
Ravi Mohan Rao
Hi all, I agree with Dr. ravi mohan Rao. this can be approached with either extended endoscopic approach or orbitozygomatic. OZ approach is really not morbid procedure as we have done for cavernous sinus tumors. I feel its morbid for the surgeon if u dont have themicro saw drill. not morbid for patient.
GK thanks for posting such cases
regards
Dr.Praveen Ganigi
Consultant Neurosurgeon & Spinal Surgeon
Narayana Institute Of Neurosciences,
Bangalore- 560099
Further update on this patient [Nov '09]
Thank you for all your suggestions...
I had taken a decision to send the patient for gammaknife radiosurgery. [Radiosurgery is not available in jipmer as of now] However, there were some apprehension of cranial nerve deficits, especially optic nerve injury - and the quantum of risks that was explained to the patient was unacceptable to him.
He underwent stereotactic radiotherapy at CMC vellore two months back. He is under follow up. Symptoms persists.
Personally I feel he will eventually require radiosurgery at a future date when the risks of cranial nerve morbidity will be even higher due to previous irradiation. (or microneurosurgery) Ill update you on his response ... though that will be many years away.
4 comments:
I didn't even see the scans but I can tell you that if the residual is not causing any mass effect ie no compression on the optic apparatus just go and blast the tumor with radio surgery.
I don't suggest any aggressive treatment for residuals.
Dr Ravi mohan rao said ICA stenosis is a comlication GKS. Believe me its a very very rare complication if any and probably I will quote the incidence as 1/5000 to 1/10,000.
You all guys look very aggressive doctors suggesting some heroic treatment options when it can be done easily with radio surgery.
You all need refreshing courses in neurosurgery
Thank you for your valuable information. Actually I want information on spine surgery . Can you please give me information on spine surgery. I will be very thankful to you.
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