acromegaly
ACROMEGALY
Acromegaly is a chronic, slowly developing disease with progressive disfigurement and disability. An early diagnosis is difficult as most signs and symptoms are due to long-standing overproduction of growth hormone &/or insulin-like growth factor (IGF-I) causing metabolic, endocrine and morphological changes.
Surgical intervention is the first-line of treatment for almost all patients with acromegaly unless there are contraindications or the patient refuses to undergo the procedure.

Surgical Intervention

  • Surgical intervention is the 1st-line of treatment for almost all patients with acromegaly unless there are contraindications or the patient refuses to undergo the procedure

Patients not Eligible for Surgical Treatment

  • Medically unstable condition
  • Patients with airway difficulties and are at high risk for anesthetic complications
  • Major systemic manifestations of acromegaly:
    • Cardiomyopathy
    • Severe hypertension
    • Uncontrolled diabetes mellitus

Goals of Surgical Treatment

  • To decrease tumor burden, and cure if possible, with preservation of normal pituitary function
  • To reduce mass effect of macroadenomas on remaining normal pituitary gland tissues, the optic chiasm or nerves, and other surrounding structures
  • To rapidly lower or reduce growth hormone and insulin-like growth factor-I levels, control or prevent progression of disease, and relieve associated comorbidities

Transsphenoidal Surgery

  • Treatment of choice for all patient with microadenomas and or all patients who have macroadenomas with associated mass effect
    • In patients with macroadenomas without mass effects, and low likelihood of surgical cure, surgical debulking may improve response to subsequent medical therapy
    • Primary medical therapy alone has also been advocated for those with macroadenomas not likely to be cured by surgery
  • Transnasal endoscopic procedures have shown improved patients satisfaction and shorter hospital stay compared with traditional sublabial procedures, without compromising surgical success
  • In noninvasive macroadenomas, biochemical control with normalization of insulin-like growth factor-I occurs in 40-68% of the patients
  • In intrasellar microadenomas, surgery provides biochemical control and normalization of insulin-like growth factor-I in 75-95% of patients
  • Surgery requires expertise to achieve control rates
  • Some clinicians have found benefits with the use of somatostatin receptor ligands (SRL) prior to surgery
    • Some have claimed pretreatment with SRLs have improved normalization of growth hormone and insulin-like growth factor-I after surgery and shorten the duration of hospital stay
Outcomes
  • Surgical cure rates are dependent on anatomy, extent and invasion of tumor and neurosurgeon expertise
  • Cure rates for intrasellar microadenomas can reach 75-95% and 40-68% for macroadenomas with an experienced neurosurgeon and facility
  • Control suggests GH levels <1 ng/mL (with IRMA or chemiluminescence assay after an oral glucose load of 75 g of glucose orally followed by GH measurements every 30 minutes for 120 minutes) and normalized age and gender matched IGF-1 levels and alleviation of tumor mass effects
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