Patients with acromegaly, Cushing's disease (CD), Nelson's syndrome, or a prolactinoma unresponsive to dopamine agonist therapy are candidates for pituitary radiation therapy. Although medications may control excessive growth hormone (GH) secretion in patients with acromegaly and excessive cortisol production in patients with CD, no current medical therapy cures the disease. Thus, definitive therapy is necessary, and pituitary radiation offers the possibility of remission or cure. In patients with acromegaly, CD and Nelson's syndrome, the first treatment is usually surgery to remove as much of the tumor as possible. If there is residual disease, then medical therapy is given to control hormone hypersecretion (acromegaly, CD). In patients with a prolactinoma who do not respond to dopamine agonist therapy (approx 8% of patients), additional treatment, which may include surgery and radiation therapy, is indicated. Even though a large invasive tumor cannot be cured with surgery, the resulting reduction in the size of the lesion helps to decompress the optic chiasm, relieve the mass effect (e.g., headache, visual loss), and provide a small "target" for stereotactic radiotherapy. Because a limitation of Gamma Knife radiosurgery is the distance between the tumor margin and optic chiasm, the appropriate candidate for this treatment is a patient with a small residual tumor or a tumor confined to the cavernous sinus, which minimizes the risk of damage to vision.
It is also necessary to diagnose and treat promptly any new pituitary hormone deficiency or deficiencies resulting from radiation therapy. Thus, these patients require regular medical and endocrinologic monitoring to assess the effect of Gamma Knife therapy and the need for hormone replacement therapy.
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