Task Group 101 of the AAPM has prepared this report for medical physicists, clinicians, and therapists in order to outline the best practice guidelines for the external-beam radiation therapy technique referred to as stereotactic body radiation therapy (SBRT). The task group report includes a review of the literature to identify reported clinical findings and expected outcomes for this treatment modality. Information is provided for establishing a SBRT program, including protocols, equipment, resources, and QA procedures. Additionally, suggestions for developing consistent documentation for prescribing, reporting, and recording SBRT treatment delivery is provided.

https://aapm.onlinelibrary.wiley.com/doi/pdf/10.1118/1.3438081

Stereotactic body radiation therapy: The report of AAPM Task Group 101

Prolactinomas account for approximately 40% of all pituitary adenomas and are an important cause of hypogonadism and infertility. The ultimate goal of therapy for prolactinomas is restoration or achievement of eugonadism through the normalization of hyperprolactinemia and control of tumor mass. Medical therapy with dopamine agonists is highly effective in the majority of cases and represents the mainstay of therapy. Recent data indicating successful withdrawal of these agents in a subset of patients challenge the previously held concept that medical therapy is a lifelong requirement. Complicated situations, such as those encountered in resistance to dopamine agonists, pregnancy, and giant or malignant prolactinomas, may require multimodal therapy involving surgery, radiotherapy, or both. Progress in elucidating the mechanisms underlying the pathogenesis of prolactinomas may enable future development of novel molecular therapies for treatment-resistant cases. This review provides a critical analysis of the efficacy and safety of the various modes of therapy available for the treatment of patients with prolactinomas with an emphasis on challenging situations, a discussion of the data regarding withdrawal of medical therapy, and a foreshadowing of novel approaches to therapy that may become available in the future.

/pdf/advances-in-the-treatment-of-prolactinomas-5a8n14833q.pdf

Advances in the treatment of prolactinomas.

Cushing's disease (CD), or pituitary-dependent Cushing's syndrome, is a severe endocrine disease caused by a corticotroph pituitary tumor and associated with increased morbidity and mortality. The first-line treatment for CD is pituitary surgery, which is followed by disease remission in around 78% and relapse in around 13% of patients during the 10-year period after surgery, so that nearly one third of patients experience in the long-term a failure of surgery and require an additional second-line treatment. Patients with persistent or recurrent CD require additional treatments, including pituitary radiotherapy, adrenal surgery, and/or medical therapy. Pituitary radiotherapy is effective in controlling cortisol excess in a large percentage of patients, but it is associated with a considerable risk of hypopituitarism. Adrenal surgery is followed by a rapid and definitive control of cortisol excess in nearly all patients, but it induces adrenal insufficiency. Medical therapy has recently acquired a more important role compared to the past, due to the recent employment of novel compounds able to control cortisol secretion or action. Currently, medical therapy is used as a presurgical treatment, particularly for severe disease; or as postsurgical treatment, in cases of failure or incomplete surgical tumor resection; or as bridging therapy before, during, and after radiotherapy while waiting for disease control; or, in selected cases, as primary therapy, mainly when surgery is not an option. The adrenal-directed drug ketoconazole is the most commonly used drug, mainly because of its rapid action, whereas the glucocorticoid receptor antagonist, mifepristone, is highly effective in controlling clinical comorbidities, mainly glucose intolerance, thus being a useful treatment for CD when it is associated with diabetes mellitus. Pituitary-directed drugs have the advantage of acting at the site responsible for CD, the pituitary tumor. Among this group of drugs, the dopamine agonist cabergoline and the somatostatin analog pasireotide result in disease remission in a consistent subgroup of patients with CD. Recently, pasireotide has been approved for the treatment of CD when surgery has failed or when surgery is not an option, and mifepristone has been approved for the treatment of Cushing's syndrome when associated with impairment of glucose metabolism in case of the lack of a surgical indication. Recent experience suggests that the combination of different drugs may be able to control cortisol excess in a great majority of patients with CD.

The Treatment of Cushing's Disease

Background
Autonomous control of surgical robotic platforms may offer enhancements such as higher precision, intelligent manoeuvres, tissue-damage avoidance, etc. Autonomous robotic systems in surgery are largely at the experimental level. However, they have also reached clinical application.

Methods
A literature review pertaining to commercial medical systems which incorporate autonomous and semi-autonomous features, as well as experimental work involving automation of various surgical procedures, is presented. Results are drawn from major databases, excluding papers not experimentally implemented on real robots.

Results
Our search yielded several experimental and clinical applications, describing progress in autonomous surgical manoeuvres, ultrasound guidance, optical coherence tomography guidance, cochlear implantation, motion compensation, orthopaedic, neurological and radiosurgery robots.

Conclusion
Autonomous and semi-autonomous systems are beginning to emerge in various interventions, automating important steps of the operation. These systems are expected to become standard modality and revolutionize the face of surgery. Copyright © 2011 John Wiley & Sons, Ltd.

Evolution of autonomous and semi-autonomous robotic surgical systems: a review of the literature

In March 2011, the Acromegaly Consensus Group met to revise and update the guidelines on the diagnosis and treatment of acromegaly complications. The meeting was sponsored by the Pituitary Society and the European Neuroendocrinology Association and included experts skilled in the management of acromegaly. Complications considered included cardiovascular, endocrine and metabolic, sleep apnea, bone diseases, and mortality. Outcomes in selected, related clinical conditions were also considered, and included pregnancy, familial acromegaly and invasive macroadenomas. The need for a new disease staging model was considered, and design of such a tool was proposed.

/pdf/a-consensus-on-the-diagnosis-and-treatment-of-acromegaly-ezu7d7swu0.pdf

A Consensus on the Diagnosis and Treatment of Acromegaly Complications

Gamma Knife radiosurgery is an effective treatment for meningiomas. However, it may be difficult to deliver what is currently considered an optimal dose, especially if the tumor is large or adjacent to critical structures. Eleven cases are presented with a follow-up of more than 12 months where the margin dose did not exceed 10 Gy. The mean age was 48.8 years. The mean follow-up period was 35.7 months (range 21 to 57 months). The mean volume of the tumors was 9.4 cm3 (range 1.6 to 28.9 cm3). The margin dose was less than 10 Gy in all 11 cases, due to a large volume in two cases. Four tumors were close to the visual pathways. Five tumors were close to the brain stem. Imaging follow-up showed that four tumors had shrunk after radiosurgery. The remaining seven cases remained unchanged. There was no tumor growth after radiosurgery. A transient oculomotor palsy was observed in two cases after radiosurgery. It is suggested that Gamma Knife radiosurgery using lower dosage than usual is one of the options for the treatment of meningioma.

Low-dose radiosurgery for meningiomas.

ヨード造影剤の重度アレルギーを持つ症例では，通常の造影剤を用いた頚動脈ステント留置術が困難となる．我々はヨード造影剤を全く用いずに奏功した頚動脈ステント留置術の1例を経験したため報告する．83歳，男性，高位の症候性頚部内頚動脈狭窄症に対して頚動脈ステント留置術を計画したが，精査の過程でヨード造影剤による粘膜疹が出現し，内科加療での再発予防を行った．しかし，脳梗塞再発を認め，ヨード造影剤を用いない頚動脈ステント留置術を施行した．Canon社製AlphenixとワークステーションAWSを用いて，透視画像に頚部MRI time-of-flight画像をfusionすることで，ヨード造影剤を使用せずに頚動脈ステント留置術が可能となった．本手技はワークステーションを利用すること以外は，従来の手法と技術的側面がほとんど変わらないため，造影剤を使用しない頚動脈ステント留置術のための有効な手段であると考えられた． 

Usefulness of carotid artery stenting by using cervical MRI fusion imaging for patients with severe allergy to iodinated contrast medium—Approach and challenges—

Object. The purpose of this study was the analysis of a large series of patients treated with gamma knife radiosurgery for pituitary adenoma in a single institution. Methods. One hundred eight patients with pituitary adenomas were treated over the last 7 years. Seventy-four patients have been followed for more than 6 months and form the basis of this report. Conclusions. Twenty-three patients harbored nonfunctioning adenomas, and 56 harbored functioning adenomas. The mean margin dose was 22.5 Gy (nonfunctioning adenomas, 19.5 Gy; functioning adenomas, 23.8 Gy). Control of tumor growth was achieved in 91%. A significant decrease of excessive hormone production was seen in 80% of patients, and the endocrinological normalization rate was 30.3%. Postradiosurgical complications were seen in 2.5%.

Gamma Knife radiosurgery for pituitary adenomas.

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Low-dose radiosurgery for meningiomas.

Usefulness of carotid artery stenting by using cervical MRI fusion imaging for patients with severe allergy to iodinated contrast medium—Approach and challenges—

Gamma Knife radiosurgery for pituitary adenomas.