Metastases to the Pituitary Gland

Daniel R. Fassett, M.D.; William T. Couldwell, M.D., PhD

Disclosures

May 18, 2004

Treatment for Pituitary Metastases

Multiple treatment modalities exist for pituitary metastases including resection, radiation therapy, and chemotherapy.[17] Because of the rarity of this tumor and its association with end-stage metastatic disease, no significant studies are available in which these various treatment modalities are compared.

Resection has most commonly been performed via a transsphenoidal surgical approach, but subfrontal and other approaches have been reported. Gross-total resection is difficult for a number of reasons, including the vascularity of the tumor, resulting in heavy bleeding; local invasiveness into the surrounding bone and cavernous sinus; and infiltration of the hypothalamus and optic nerves.[7,10,17] Reports on two surgical series have indicated no difference in survival attributed to resection. In a review of 36 patients with symptoms, Morita, et al.,[22] found no statistically significant difference in survival in the 21 patients who underwent surgery. The authors did note an improvement in survival times when local tumor control was achieved, but this usually required multiple treatment modalities. They also found an improvement in symptoms (visual acuity, pain, and ophthalmoplegia) and quality of life after aggressive tumor resection and radiation therapy. Other authors have confirmed improved quality of life, but no survival benefits associated with surgery.[3] Of the presenting symptoms, anterior pituitary hormonal dysfunction appears to be the least likely to improve in response to aggressive management.

In most series adjuvant radiation therapy has been used for pituitary metastases, but there is debate about whether the radiation should be directed to the parasellar region alone or to the entire brain. Proponents of limited parasellar region irradiation favor a limited field to reduce the side effects of whole-brain irradiation. Those favoring whole-brain irradiation have noted that these tumors can spread via meningeal pathways or by direct extension out of the limited treatment field. At this time, there are insufficient data to support one radiotherapy philosophy over the other. Although not reported in the literature, radiosurgery may have a role in the treatment of pituitary metastases.[10]

Chemotherapeutic agents have been widely used, but success rates have not been published in the literature on pituitary metastases. As chemotherapeutic advancements continue for the treatment of these malignancies, we may see improvements in outcome.

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