Surgery remains the most appropriate treatment to relieve chiasmal and optic nerve compression and to reduce hormone hypersecretion. Patients with residual or recurrent NFPA may be offered conventional or high-precision external beam radiotherapy delivered in a fractionated manner using multiple fields to a dose of 45 Gy in 25 fractions. The most appropriate timing of radiotherapy after surgery is not defined. The morbidity of treatment is low, with the requirement for hormone replacement therapy the most frequent consequence. Persistent hormone elevation is successfully treated with radiotherapy, particularly in acromegaly and CD although the normalization of hormone levels occurs with delay. In the treatment of prolactinomas, radiotherapy is appropriate for patients who do not tolerate medical treatment and where dopamine agonists have failed. Patients with CD treated with bilateral adrenalectomy are at risk of developing Nelson's syndrome and prophylactic pituitary radiation reduces the risk of tumor growth.
Although radiotherapy is an effective and relatively nontoxic treatment, its role has become accepted without evidence from prospective randomized trials. As a result, many questions, particularly about its long-term effects, remain unanswered. New technological developments in radiation delivery are generally equated with progress and are believed to represent improvement in patient outcome. However, the issues of radiation and its long-term consequences persist and early results, equivalent to those for conventional radiotherapy, are no proof of benefit. In addition, the uncritical acceptance of novel techniques and technologies may yet have unforeseen disadvantages, such as presumed but unproven accuracy of tumor delineation, that may lead to inferior treatment results. Prospective randomized trials evaluating the role of radiotherapy, particularly the critical endpoint of survival, are therefore urgently needed and studies should include not only conventional radiotherapy technology but also all apparently innovative radiotherapy techniques.
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