Pituitary targeting for intractable cancer pain : a systematic review and current recommendations

Introduction Most patients suffering from cancer will face pain during the course of their disease. Pain is a source of major discomfort, and alteration of quality of life. Pituitary targeting, initially reported as hypophysectomy, was first proposed to control endocrine cancer. Although this technique didn’t improve the overall tumoral control, it rapidly showed an interesting effect on cancer pain related to bone metastases. Due to the complications, this technique gradually decreased and finally fell into disuse. Recently, some authors have shown a regained interest in pituitary targeting using a radiosurgical procedure, in order to limit surgical complications, with interesting results Methods We performed a systematic review of the literature and meta-analysis with the aim of evaluating the outcome and complications of pituitary targeting, then determine its current place in the management of cancer pain. Results 24 studies were included in this systematic review (700 patients). 19 studies reported the results of surgical and 5 studies of stereotactic radiosurgical pituitary targeting. Pain relief was reported in 82.2% and 93.5% for surgery and radiosurgery, respectively. On the long-term, pain relief was maintained in 80.2% and 88.6% for surgery and radiosurgery, respectively. Complications varied among treatment modalities, with diabetes insipidus being the most common complication. Conclusion Pituitary targeting remains an attractive option for refractory cancer-related pain after failure of traditional therapies. Radiosurgery is a promising treatment modality due to its high success rate and reduced risk of complications and should be recommended over surgery whenever possible. Pain relief is presumably related to a neuromodulation mechanism.