Temozolomide treatment for aggressive pituitary tumors: correlation of clinical outcome with O(6)-methylguanine methyltransferase (MGMT) promoter methylation and expression

Abstract

Context: The typically indolent behavior of pituitary tumors is juxtaposed with high rates of tumor cell invasion into adjacent dural structures, and occasional aggressive behavior. Although clinically significant invasion and malignant transformation remain uncommon, there are limited treatment options available for the management of these aggressive tumors. Recently, case reports have described efficacy of temozolomide for the treatment of aggressive pituitary tumors.

Design: Seven patients with aggressive pituitary tumors have been treated with temozolomide. We compared O(6)-methylguanine methyltransferase (MGMT) promoter methylation and MGMT expression in 14 surgical specimens from these seven patients and correlated these molecular features with the clinical response to temozolomide.

Results: Significant tumor regression was seen in two patients (29%), a 20% reduction in tumor volume with subsequent stable tumor size was noted in one patient, arrest of tumor growth occurred in three patients, and progressive metastatic disease developed during treatment in one patient. The DNA promoter site for MGMT was unmethylated in all 14 adequate specimens, and variable MGMT expression was seen in all 14 cases. There was no correlation between MGMT expression and clinical outcomes.

Conclusions: We conclude that medical therapy with temozolomide can be helpful in the management of life-threatening pituitary tumors that have failed to respond to conventional treatments. The optimal duration of treatment in patients with stabilization or reduction of tumor size has not been established, and long-term follow up studies are needed.

Fig. 1.

Serial T1, Postcontrast MRI images before and after temozolomide treatment. A and B, Case 2, an invasive corticotroph tumor pretreatment (A) and after 11 cycles (B) (arrows highlight tumor extension). C and D, Case 5, an invasive prolactinoma pretreatment (C) and after 8 cycles (D) (arrows highlight substantial reduction of tumor).

Fig. 2.

Serial MRI images from case 4. A–E, Progressive tumor growth in a patient with no history of radiation treatment. E, Immediately before temozolomide; F, arrest of tumor growth during eight cycles of temozolomide.

Fig. 3.

IHC for MGMT. A and B, Diffuse pattern of stain (score 2); C, strong stain (score 3); D, example of heterogeneous stain in a single focus; E, internal positive control endothelial cells; F, internal positive control sinus mucosa.

Fig. 4.

Pre- and posttemozolomide treatment specimens from case 2. A and B, Surgical specimen before GammaKnife radiation and temozolomide treatment showing extensive cellular atypia (A) and high Ki-67 labeling index (18%) (B). C–F, Surgical specimen after treatments and collected during CSF leak correction showed focal islands of tumor cells entrapped on fibrous connective tissue with intense inflammatory reaction (C). Extensive cellular pleomorphism was present (D), but adenoma cells were still immunoreactive for ACTH (E). Ki-67 labeling was practically absent on tumor cells, but present in inflammatory cells seen on the specimen (F).